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How Safe is Your Dental Practice Revenue from Claims Repricing?

Medical costs for a medical procedure can vary from one medical provider to another, by hundreds and, sometimes, even thousands of dollars. Costs can also vary by whether a provider is in-network or out-of- network with an insurance plan. What is the role of insurance claim repricing when it comes to paying for medical services? How can you ensure that your practice is making the most revenue and making the best of claims repricing? In this article we will discuss how claims repricing works and how you can prevent loss of revenue in your dental practice due to claims repricing.

What is Claims Repricing?

When a medical or dental practice treats a patient, a claim report is filed with a patient’s insurance company. This claim contains a detailed description of the care received by the patient, such as medication the patient received, procedures performed on the patient, material used for treatment and provider’s fees.

Once a claim is received, insurance companies adjudicate if the patient is eligible for the service that was received based on the terms of their insurance plan. Then, the charges are repriced based on the terms of the contract between the insurance carrier and the medical provider. The information is sent back to the medical provider, along with the amount owed. The patient can then be billed the remaining, new out of pocket charge that the insurance company has dictated.

For example, a claim from a medical provider may be very detailed and include several individually priced items on a list. However, an insurance company may only allow a set amount for a medical service per a contract, so the claim amount and the billed amount can vary in price. Allowed amounts can vary depending on geographical location, whether a provider is in or out of network with the patient’s insurance and the average charges of other practices in the general area.

Claims repricing is, in effect, a determination by the insurance company of how much of your dental practice’s set fee will be paid and now much will be passed on to the patient, after the services performed have been approved and paid according to the insurance company contract. Of course, you want to avoid passing on too much expense to your dental patients, or risk having them move to another practice with better pricing practices.

What are the Benefits of Claims Repricing?

Claims repricing can be beneficial to both a business and the customer receiving a medical service. Billing errors are common in medical and dental practices due to large amounts of paperwork. Medical claims repricing can help eliminate errors that increase costs and lead to underpayments or overpayments on insurance claims.

Insurance companies have a set amount that can be paid to providers for select services. This is meant to avoid instances where customers are overcharged. By having a claims repricing process, insurance companies can also monitor for fraud by overstatement of claims, by frequently checking and validating claims that are submitted. This prevents consumers from paying larger out-of-pocket expenses that are not necessary.

How Can Claims Repricing Affect my Practice?

Claims repricing can affect the revenue of your business either negatively or positively. For example, a patient with Pretty Smiles dental insurance comes into your practice for a root canal. You expect to get paid $750 for this service from insurance, since this is the total cost for materials and labor. You send the claim to the patient’s insurance, but Pretty Smiles only allows $600 for a root canal procedure. Simply explained, your dental practice is spending more than it is earning in this scenario.

Another scenario could see a patient coming to your dental practice for a routine cleaning and exam with Happy Smiles insurance. Your dental practice is not in-network with Happy Smiles, but you are connected with other networks that participate with Happy Smiles. After submitting a claim for $300 to cover the exam, x-rays and dental cleaning procedure, claims repricing by the insurance company’s adjudication system reduces the amount paid to you by Happy Smiles to $198. Since you are not in-network with Happy Smiles, you are reimbursed at the lowest possible cost for these provided services.

In this case, your dental practice should investigate whether it should become in-network with Happy Smiles to obtain a better rate, or simply refuse to accept Happy Smiles insurance because of such a low reimbursement rate. If you only see a patient here or there that has Happy Smiles insurance, your practice may be better off refusing the insurance.

How Can I Make the Best of Claims Repricing?

There are a few ways that you can avoid losses due to claims repricing. When filing a claim, charge standard rates, but ensure that what you are charging is updated and in line with what is being charged at similar dental practices in your area. Assess which insurance providers you are in-network with and whether it is beneficial to your business.

For example, 20% of your client base may have a Pretty Smiles insurance plan, so it would be important to be in-network. Adjusting your pricing to work with this company will earn you more through patient volume over time. Another way to prevent losses is to protest any involuntary changes made during claims pricing that could affect your current clients. This is best done in writing to maintain a paper trail.

You should also consider utilizing a professional company that specializes in PPO negotiations. PPO Negotiation Solutions is a company that can help navigate claims repricing, increasing your reimbursements by nearly 24% and minimizing losses to your existing clientele.

The most important focus in your dental practice is your patients. Do not let insurance struggles and stress over reimbursement get in the way of quality patient care. Contact PPO Negotiation Solutions today to increase your practice revenue, so you can continue providing excellent patient care.

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5 Tips to Grow Your Dental Practice

Every dental practice wants to experience healthy growth. It is important to continue working on ways to improve and grow your dental practice. Patient satisfaction and safety are the goals, but financial success and the satisfaction of your team members are also important for success! Some tips include setting short and long-term goals, investing in your team, maintaining a positive work environment, and increase or change your marketing strategies. Let’s explore these in more detail.

Set Goals

Identify what needs you have in your practice. Notice trends and analyze data. One business blog suggests using tools to assess your needs, such as SWOT analysis, benchmarking, market research, trend analysis, and attending webinars. Once you have identified your needs, set your goals. Goals should be specific, measurable, attainable, relevant, and time-bound (S.M.A.R.T. goals). Always set a time frame to achieve each goal and prioritize your goals for orderly pursuit and success.

In order to achieve a goal, you need a plan. How much time do you expect to need to achieve your short and long-term goals? Obtain resources, set your budget, and assign responsibilities to those participating in the process. It is helpful to measure results throughout the process as well as at the end. Measuring results can assist in the setting of new goals. Never stop asking, “How can we do this better?”

Invest in Your Team

Team members should be adequately trained for the position they hold and have the tools needed to perform efficiently. This could include leadership training, sales training and human resource training. Don’t forget opportunities for professional advancement. Having good and open communication with your team allows them to communicate their workplace needs. Well-trained employees can make all the difference in a successful thriving business.

Investing in your team does not just apply to their training, however. Treat your team members with respect. Invest in what will make them satisfied working at your business. Show them appreciation often and be sure to inquire about what would help the workplace morale. Happy team members are more likely to invest time and effort into their work, leading to increased revenue and patient satisfaction for your practice. What are some ways that you are currently investing in your team? How could you improve?

Maintain a Positive Culture

A positive work environment is essential to a successful business. Your team should be clear on expectations and standards. Positive culture should carry over to patient care. Patients then should also be clear on expectations and standards. Positive work environments can be obtained by keeping a positive attitude, having open communication with team members, and maintaining a culture of respect. Allow for your team members’ feedback – good and bad! Prioritize respect, diversity, and inclusivity.

Maintaining a positive culture also means ensuring that you are hiring the right team members into your culture. When hiring new staff, keep your current staff dynamics and needs in mind. It could be helpful to do peer interviews and invite your team members’ opinions on the potential hire. Hiring the wrong person could have a negative effect on your practice culture. Your practice’s culture is what you make it!

Increase Marketing

News flash! You need patients to have a dental practice! Your biggest marketer is a body of satisfied patients; with this dynamic at work, your business will grow through word-of-mouth advertising, which is really the best form of marketing. As a dental provider, you need to ensure that your current patients trust you to provide them with quality care and invest in their health.

Take it up a notch and do follow-up personal calls to patients or send personalized mail. Begin a regular monthly email newsletter to keep your patients informed. People value trust and respect, especially with their health care providers. Direct connection establishes loyalty. Loyal patients will continue investing in your business and market your business, as well. Social media is another popular way to market your business.

If you do not already have a website, get one and keep it updated with the services you offer, schedules, and even a bio profile of your employees to make it personable. Promoting ads on social media platforms is another option. According to an ad by Forbes, social media marketing is critical, with almost a third of 16-24 year-olds learning about new products and services through paid ads on popular social media platforms. It goes on to state that social media is a popular way that customers hear about new products.

Get Professional Help

A professional company to assist in marketing your practice is also an option. Some companies can not only assist in marketing but also provide training and marketing strategy management. If you are not familiar with managing a website or social media, consider hiring a professional to do so. It can make all the difference when looking to gain new clientele.

Strategic Practice Solutions is your one-stop shop for assistance with training your team, setting your goals, and being proactive in growing your dental practice. Do not settle for mediocre when you can accomplish more with the help of a team of experts. We are ready to help you be successful! Contact us today and start growing your business!

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How to Make UCR Work for Your Practice

How your dental practice gets paid is of supreme importance. There are numerous elements that surround the entire area of accounts receivables, and it literally “pays” be know how these aspects factor into your overall income strategy. A working knowledge of UCR can actually benefit your dental practice and help you avoid financial losses.

First, let us define what UCR is as it pertains to dentistry. The acronym stands for usual, customary and reasonable. However, to many dentistry practices, it seems rather unreasonable and not at all fair. Basically, the term UCR applies to the fees and reimbursements that insurance companies pay to dentistry offices for services. It has been adopted by dentistry and can be found on EOB (Explanation of Benefits) forms that offices use to request reimbursement from insurance plans. Since the reimbursement amounts can often seem unfair, here are some ways to make UCR work for your practice and avoid taking a financial loss.

Understanding UCR

UCR is not actually a number; instead, it is a range of numbers based on percentages. Insurance companies will pay out a certain percentage based on the cost of a dental procedure. Even though it is based on percentages, there is also a cap on how much the company will pay for each procedure and insurance will pay out whichever cost is less. Zip code and percentage plays a large factor in determining UCR at insurance companies. Geographical area has some weigh-in on the amount that insurance will pay. Let us look at an example.

In your geographical area, let us assume that the majority of dentists chart $200 for a crown; so, the insurance company would set the fee at $200. Let us say that your office charges $150 for crowns. A patient’s insurance plan pays 50% toward the charge, which is $75, leaving a $75 remaining balance. In another scenario, let us say your office charges more than the average $200; say you charge $300. Insurance would still pay 50%, or $150 and there would be a $150 balance remaining.

How UCR Affects Your Practice

Dentist offices may be forced to lower charges for services in their area to retain clients. However, lowering charges for services too much can result in a financial loss to the business. Knowing UCR levels could mean increased revenue for your business.

An article details a hypothetical scenario about an average dentist office’s profit: “…dental practice grossing $400,000 per year. The average overhead in a $400,000 practice is 70 percent. If our hypothetical office is open 40 hours per week, 50 weeks per year, then the dentist works 2,000 hours per year. The office overhead is $280,000. Total overhead ($280,000) divided by 2,000 hours gives us an hourly overhead of $140. That is the fixed overhead before the doctor is paid a single penny.

Now say a patient were to come in needing a prophylactic cleaning and claimed it to be covered at 100%.” …the office submits the claim form. The fee for the cleaning was $85, the overhead cost was $140, and the doctor`s/hygienist`s salary must be added to that. The office just lost $55, plus the salary of the doctor/hygienist.”

In another explanation of the effects on patients and business, it is stated, “In situations where a single company serves one geographical area, their usual, customary and reasonable fee schedule affects the prices of dental services in the area. Where a dentist charges more than the set usual, customary and reasonable fees, they have no option but to lower their fees in line with the average charges in the area. Consequently, when a dentist realizes that they charge less than what is set in their area of practice, the chances are that they will raise their fees.”

How to Make UCR Work for You

One item on your agenda should be analyzing your fees. By assuming that you will only be reimbursed 70%, for example, you could be losing money. Different plans could be paying 80% or even 90% but could be reimbursing you less money because you are charging less for your services. Routinely monitor your EOBs (explanation of benefits) and find out which plans cover at what percentages.

Pre-certification and pre-authorization are easy steps to take to ensure maximum benefits. Pre-certification verifies that a patient is active with an insurance plan. Pre-authorization involves submitting a request for treatment to insurance for payment. Some insurance companies require this for payment! Verifying benefits can be combined with the pre-authorization process. You want to be sure that the procedure you are requesting to be performed is covered under the patient’s insurance plan.

So how can companies like PPO Negotiation Solutions help your business? PPO Negotiation Solutions has an eight-step process to save you money and increase your revenue. Part of that process is to evaluate your current UCR and PPO fee schedules in comparison with other dental practices in your area. Also work on PPO fee negotiations, provider credentialing, and staff education. Let the experts educate you and set you on the path to success. Call or click today!

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Tips for Dental Insurance Credentialing

As a dental practice, you are likely investing ample time and energy in your patients, to ensure the best patient outcomes. But are you also investing enough time and energy to ensure you are getting the most opportunities for growth and profit? Since organizational growth and development equals positive patient outcomes, let us look at some successful tips for dental insurance credentialing.

Importance of Credentialing

First, it is important to understand why credentialing is important. In short, credentialing is the process of verifying a dentist’s background for an insurance company. Patients are now more likely to choose to go to providers that are in-network with their insurance due to costs. It is very important to be credentialed with various insurance plans. By credentialing with a various number of popular plans, client base can be greatly increased.

Assess Opportunities

Assess your opportunities for growth. If your dental practice is in a populated area, explore different employers in your local community. Are there large organizations that carry a particular plan? If you were to enroll in their plan, is there potential for a large gain in clientele? Consider other competing dental practices in the area, as well.

Enrolling in a large organization’s plan could increase competition between you and other practices. Contact the large organization’s HR department for marketing. But be sure to understand all the details of the plan first to avoid any unneeded stress on your practice. Evaluate the potential workload and ensure your staff is equipped to handle the increase in workload.

An example scenario for seizing an opportunity for growth would be a large healthcare chain in your local area that owns several local hospitals, walk-in clinics and offices. You contact the HR department of the chain and find that they use a particular insurance plan for the entire healthcare chain. Enrolling in this plan would make you an in-network provider to all employees of this chain, increasing your potential client gain.

Consider Current Clients

Consider your current clients. Are the majority in-network or out-of-network with your current plans? If you were to make a major change, how would that affect your revenue? There may be the possibility of losing current clients if you were to no longer accept their insurance plans at your business. On the other side, could changing to this plan be beneficial to the majority of your current patients? It may allow patients to receive more dental care or procedures they otherwise could not afford. Your current patients’ satisfaction is equally as important as gaining more clients.

To place this point in perspective, say your clinic has approximately 50% of clients with one plan and 50% with another major plan. If your clinic were to go out-of-network with one of the major plans, you could potentially lose 50% of your patients if they were to decide to switch to a different office that was in-network. If a large amount of your patients are out-of-network with a plan and could be in-network, you could make a larger profit and the patient may have more benefits, as well.

Reimbursement Opportunities-Negotiation

Using a skilled negotiator to negotiate fees and credential scheduling can be a useful tactic. Stay up to date on the latest information about popular insurance plans. Even though some insurance companies advertise that they are non-negotiable, ask to negotiate! Some plans will only offer negotiation if you are a specialist, so be mindful and consider hiring a negotiator. Be aware of third-party companies. They may have better scheduling, but there could be hidden costs.

If needed, consider outsourcing negotiations until your staff is up to date. The American Dental Association posted an article on their website, encouraging dental companies to negotiate with insurance companies. The article stated that companies used to negotiate with insurances were “on the rise” and a doctor in the article mentioned that it allowed her more time to focus on her patients. Carefully consider which negotiation specialist is right for you and your company.

Dig Deeper

More profit for your business could be obtained by ensuring that you are not underutilizing dental codes. Are you aware of all the dental plans in which you are enrolled? Ensure your staff is adequately trained to code reimbursement forms effectively. Optimizing your insurance plan’s coding tools effectively is essential to ensure increased revenue and to ensure the best patient outcomes. Another tactic is to explore the cash prices being charged by other dentists in your area. You want to be sure you are charging enough for your services.

Company Contracts

Consider contracts with companies to do negotiations for you. How can companies like PPO Negotiation Solutions be helpful? They can increase insurance reimbursements, create new patient opportunities and decrease negative impacts on patients. The Mission of PPO Negotiation Solutions is to “enrich dental practices, not only through increasing their revenue, but also their understanding, while streamlining processes for optimal day to day well-being.”

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How to Build a Successful Dental Practice

Dental medicine is a thriving industry with enormous potential. However, that does not guarantee that your dental practice will automatically become successful. Dental medicine has evolved over recent years to become more advanced, more appealing and more comfortable for patients.

The modern dental practice has numerous moving parts and functional systems to keep it operating at peak efficiency. Modern medical care, including dentistry, is a complicated combination of treating patients and running a business. Both sides of the equation must be balanced in order to build and maintain a successful dental practice.

This is where many dental practitioners experience a serious disconnect – they fell in love with dental medicine but likely choke when dealing with all the necessary evils of the business component. A successful dental practice requires acumen in both areas: dental care and business management.

PPO Negotiation Solutions knows what it takes to make your dental practice successful. Whether you are just starting out in practice or you’ve been in business for years, we can offer suggestions and solutions to transform your dental practice from serious drudge to unparalleled success. Here are some basic strategies we suggest.

Competitive Branding

A successful dental practice sets itself apart from the local competition. Learn about the target population in your area, their needs and desires for dental care. Then, find a way to meet those needs and desires with your own competitive advantages. These unique advantages are the major focus of your sales and marketing strategies. Highlight what makes you different and better than the other local dental practices.

It is not enough to feature what every other dental office in the area provides. Some cool amenities and a fancy building still houses the same dental care options that most other dentists offer. You must determine what makes you stand apart from the rest and make that a major focus.

For example, children’s dentists were scare in a particular area, although there were several dental practices from which to choose. One particular dental practice opened with unique branding that focused more on pediatric dentistry, even featuring a circus design motif and décor. Their business almost exploded with growth virtually overnight.

Competent Care

Competitive branding will attract clients, competent care will keep them coming back for years. You must attract and recruit talented and skilled practitioners who know their business. They are the face and hands of your dental practice, and they are the single most important factor that will cause clients to return or go elsewhere.

Skills and personal interactions are equally important. Kind and compassionate treatment combined with unsurpassed dental treatments are a winning combination that will keep your practice thriving. The right team exudes an atmosphere of teamwork and family. That kind of office culture is a huge plus for attracting and keeping quality team members.

Don’t underestimate the success power of a great team, nor the destructive power of an unhappy or problematic team. It may pay off in the long term to contract with professional recruitment services to help you screen and evaluate candidates. This is especially true if in addition to owning the practice, you also personally provide full-time dental services.

Comprehensive Services

Modern people are busy – the number one barrier to most people receiving dental care is a busy schedule. You can trump this argument by providing a comprehensive array of dental services to meet any need. Beyond providing excellent care, you must provide the full range of dental services that your clientele may need.

Patients no longer wish to go to several dental specialists’ offices for numerous appointments. They want one dentist and one office to handle their dental needs. This includes everything from pediatric dentistry to basic and emergency care to replacing teeth in their older years. While recruiting a talented and skilled team, be sure to adequately cover all the bases so you can offer every dental option under one roof.

Dental technology has expanded to include advanced imaging, lab and treatment options that can all be housed in a single practice. It may require a challenging investment up front, but your clients will be more than happy to stick with your dental practice when they can enjoy the latest and best dental care in one place and with one team they know and trust.

Make It Easy for Clients to Get Care

Most people are only offered dental care as an addition to regular insurance coverage, meaning it is often viewed as an extra burden. As of 2019, the CDC reported that only 50.2% of adults between the ages of 18–64 enjoyed the benefit of dental insurance coverage. This means that approximately half of your target clientele have no assistance with paying for dental care.

Targeting this half will require adding some creative payment options that make it easy for clients to get the care they want and need. Flexible financing options can open the door for many of these potential clients when they have no dental insurance coverage. Moreover, many others who do have insurance have limited coverage that does not completely pay for some treatments. Take the necessary steps to accept numerous types of payment, including as many insurance companies as possible, cash, credit and debit payments and some sort of easily-obtained financing.

Be Proactive in Asking for Referrals

Word-of-mouth referrals are still the number-one method of gaining clients. People give considerable credence to the word of those they know and trust. So, make it easy for your clients to refer other clients. Ask for referrals and provide different strategies for obtaining them in different settings.

There are ways to point people to online referral pages through your email, ads and patient communications. Provide in-office referral cards and ask your clients for online reviews. Provide the necessary links to these sites and offer incentives for those who provide referrals or testimonials about their care.

Your Ultimate Success Depends on Clients

How do you build a successful dental practice? It all revolves around your clients. Targeting your ideal customer, providing them with unsurpassed dental care and a pleasant experience while at your office and maintaining a focus on attraction and service will keep clients returning for dental care over the long haul.

This means that your patients must inform every choice you make for your dental practice, including marketing, amenities, staffing and services. The client is your source of revenue, so prioritizing their experience is the key to creating and maintaining a successful dental practice.

PPO Negotiation Solutions offers many solutions to enrich your dental practice operations and profitability. Contact us today for a consultation and learn more about how we can help you build a successful dental practice.

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How Healthy is Your Practice? 5 Key Indicators

You work hard to make sure that your patients’ teeth are healthy, but how healthy is your practice? Chances are good that you spend most of your time focused on serving patients and managing your staff, but long-term stability requires focusing on things that apply to your financial big picture as well. Part of understanding what makes a dental practice healthy centers around analyzing several KPIs (Key Performance Indicators) and then using the information you find to adapt and adjust how your practice functions.

The following 5 key indicators are a great way to assess the overall health and stability of your practice so that you can make solid decisions for how to improve it moving forward into the future:

  1. Patient Scheduling Data

While the average goal across most dental practices is to have 98% of all active patients scheduled for an appointment in the near future, the typical scheduled rate falls much closer to 80-85% at best. Whether due to increased competition or increasingly busy patient home and work-life schedules, it is not uncommon to experience difficulty in filling your company calendar to the brim.

However, you need to remember that unscheduled patients are an attrition risk – if they are not actively planning to come into your clinic, you face the possibility of losing them to another dental practice that is closer, cheaper, or newer. Finding ways to keep your current patients engaged and on your schedule is one of the best ways to maintain your practice’s overall health.

  1. Your Practice’s Overhead Data

While every company has some amount of overhead costs, you need to have a firm grasp of exactly how much you are spending so that you understand the big financial picture your company is in, whether good or bad. Unnecessarily high overhead costs, especially costs that are difficult to get out of or to creatively lower can cripple your practice’s future plans and can make it difficult to grow.

On average, your overhead costs should fall well under 60% of your total cost projections. If you are in a specialty service area like oral and maxillofacial surgery or endodontics, your overhead costs should be under 50% on average. If you evaluate your practice’s overhead costs and find them to be unusually high, it would be wise to audit your spending and uncover areas of bloat that you can reduce to put additional funds back into your pocket every month. You can use the added finds to hire more staff, expand your services, or even invest in marketing.

  1. Staff Labor Data

Without a doubt, staff labor costs make up the largest financial outflow line item for any practice, often making up 25-30% of all costs. As with overhead costs, specialty clinics often see lower percentages, falling more in the 18-25% range. Knowing how much you are paying your staff is vital to your practice’s overall health. If you are operating based on guesswork, you run the risk of overlooking budgetary obligations or missing out on areas where you could be saving money.

  1. Overall Production Data

On average, the production you will see per new patient will be double or triple that of existing patients. There are many factors that play into this, but dentists often find bigger issues requiring large treatment plans with brand new patients. It is vital to track your production and revenues for new patients so that you can accurately project income and budget into the future. Knowing where you stand with new patient services also lets you have a benchmark for how much marketing you need to do to achieve your revenue and production goals.

On the other hand, average production per existing patient paints a long-term picture of how much each patient contributes to the practice’s revenue each month or each year. This is an excellent baseline measurement and budgeting tool. Typically, average production should grow year upon year as your practice grows. If you see these numbers staying the same or even declining, it may be time to add a new service to your offerings to help keep your patient base coming back to you when they need something to help keep their smiles on point.

  1. Patient Attrition Data

Patient attrition is a fancy way of saying patients that leave your practice. It refers to the number of patients a practice loses on a monthly or annual basis. The most successful practices fall almost 10% below typical attrition rates for their industry. The reason behind this is simple: If you are losing patients, you are losing revenue, and you have to invest more money in marketing or patient loss prevention efforts. The best way to keep attrition rates low is to continually look for ways to add value to existing patients and to offer the best quality services possible.

These 5 Key Performance Indicators are an excellent place to start when it comes to understanding the overall health and stability of your dental practice. Evaluate them often, and look for ways – no matter how small – to increase the positive elements and decrease those that are not performing well.

 

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