PPO Negotiation Solutions

We Level The Playing Field Between Dental Practices and Insurance Companies

Dental negotiations

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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10 Things You Need to Know About You and PPO’s

As a dentist, do you feel like you are at the mercy of the PPOs? Is writing off tens of thousands of dollars because of how you participate in dental PPOs hurting your practice? Do you feel trapped into giving deep discounts to PPOs in order to keep existing patients? If you are at a point where you are considering cutting back on PPO participation, here are ten things that you need to know when it comes to you and PPO’s.

1. You Have Much More Power Than You Realize

The insurance companies won’t make any money at all if you don’t provide the quality dental care patients need. This gives your practice the upper hand in its relationship with the PPOs. They are simply promoting the dental services you provide and taking too big a share of the money you generate. You are the one making the patients happy with the quality dental care you provide. Let the insurance company know that you will no longer provide services to patients at the repayment rate you receive. They will be forced to give you better rates or lose all the money you generate for them.

2. Dental Practices Can Thrive with Little PPO Participation Or None At All

You may be concerned that if you stop accepting PPO patients, the reduction in your patient base may reduce your production and revenue stream too drastically. But this isn’t true. Many dentists don’t accept PPO patients and still maintain a robust business with a steady stream of income and new patients. High-quality dental care retains existing and brings in new patients. If you provide excellent dental care at competitive prices, your satisfied patients will tell their family, friends and acquaintances about the quality of your dental services. Referrals will continually generate new patients.

3. Dentists Can Determine the Right PPO Participation Balance

When dentists set their own fees they charge, they strike a balance between charging fees that are too high for most patients and too low to be profitable. You can do the same thing when participating in PPO programs. You can moderate your participation in PPO programs by deciding how many PPO patients you will accept, in what plan and at what reimbursement rate. You may be willing to have only 20% of your dental patients come from PPOs and only if the PPO pays what you consider fair compensation for your dental services.

4. You May Already Have Out-Of-Network Patients

Every PPO has some patients who use out-of-network dental care providers because of their exceptional service. These services are still covered by the insurance companies. You may already have some out-of-network patients for
whom you provide care. The patient decides which dentist, in or out the PPO network, they will go to for the quality dental services they need. Dentists providing the best and most advanced dental care possible can be confident in the fees charged. The patients will make PPOs pay you to provide the dental care they need.

5. Companies Select PPOs to Retain Top Talent

Employers provide dental coverage for their employees to attract and retain top talent. PPOs are selected to save money, while providing the dental care that their employees need. Dentists providing employees with critical dental care, not covered by the PPO, are typically paid out-of-network, or the employer will drop the PPO and replace it with one willing to pay the dentist selected by their employee. That is why many insurance companies provide good out-of-network benefits.

6. You Can Drop the PPO and Keep the PPO Patients

If your staff is well-trained, highly skilled, caring, and professional, it’s possible for your dental practice to drop the PPO and yet still retain most of the PPO’s patients. This is true, as long as, the PPO offers some type of out-of-network benefits. Most patients remain loyal to their dentist they trust and feel comfortable with. These patients are willing to pay a little more out-of-pocket for excellent quality care. In most cases, if a dentist drops underpaying PPOs, they will be able to retain the majority of the PPO patients, and at a better reimbursement rate.

7. Accentuate the Positive

Whether your patient’s PPO plan considers your dental practice to be in-network or out-of-network, it’s important when talking to patients, to accentuate the positive. Let them know other patients with the same PPO use your practice. Point out PPOs generally allow patients to use any dentist they choose. Explain to your patient how you are different or better with the dental care provided to the patient. This will benefit them should it be necessary for them to get clearance from their company’s PPO plan administrator.

8. It Is Possible to Negotiate Higher PPO Reimbursement Fees

Dentists or PPO Negotiation Solutions, acting on their behalf, have successfully negotiated higher reimbursement rates from PPOs. The main reason most dentists haven’t gotten better reimbursement fees from insurance companies is because they haven’t tried. Perhaps because they don’t have the time to devote due to their busy post COVID patient schedule, or they fear patient loss, or are intimidated by the red tape that may be met with the PPOs. However, it is in the best interest of the insurance companies to keep as many dentists as possible providing services under their PPO plans. Dealing with PPOs from a position of strength, with full knowledge of relative competitive provider rates in your area, and a particular PPO’s reimbursement rate, relative to others for the same services, will ensure that the PPO compensates you fairly.

9. Consider PPO Negotiation and/or Reducing Participation

In an attempt to increase the number of patients they serve; many dentists opt to participate in PPO plans. However, over time and with careful analysis, you may soon realize you are losing tens of thousands of dollars, because of sub-standard reimbursement from insurance companies. If the PPO reimbursement rate for dental services you provide to patients is less than 80% of its actual value, you should consider first, negotiating your fee schedule with that insurance company, or possibly reducing your PPO participation.

10. Create a Strategy for Leaving The PPO

If you feel your dental practice is losing too much money serving one, or all, of your PPO patients and you have decided to leave the PPO, create a strategy that will fortify your practice and make a plan for how to replace any patients you may lose as a result . You can build up your practice in advance of terminating certain PPOs with an effective marketing strategy that will attract new patients. In this manner your production levels will not be interrupted. Make your staff aware of the changes you have planned. Share your vision for the dental practice. Provide your staff with ways to engage prospective patients responding to your marketing campaigns in order to maintain the level of success that it currently enjoys and surpass it. Your staff will play a valuable role in the transition.

Contact PPO Negotiation Solutions

PPO Negotiation Solutions has been negotiating and optimizing PPO participation since 2012. With 30 years of experience within the dental industry, our success is unparalleled in producing not only the greatest reimbursement revenue increases, but also, the most comprehensive, un-invasive approach. We provide no hassle results quickly, starting with a thorough assessment of your patient participation mix, often through remote access to your practice management software. Your fee schedules are then analyzed relative to other dental practices in your general area.
A negotiation/participation plan is formulated and agreed upon. We negotiate higher fee schedules on your behalf directly with our highly cultivated contacts within the PPOs and meticulously follow credentialing paperwork through the system until you are safely in network. Call us today to realize a minimum 24% increase in PPO reimbursement revenue. Successful completion usually means adding around $10,000 per month or $100,000 annually to your bottom-line and our service pays for itself in the first month.

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Revenue down? Get Ready to Increase Your Insurance Reimbursement

Dentists expect to be highly compensated because of their extensive time, financial and technological investment. Furthermore, dentists strive to provide the best patient experience possible with the latest procedural and technological advancements. However, little by little, PPOs encroach on that compensation and care level by reducing fee schedules over time.

What’s worse is that employees with insurance often tend to select a dentist from a list of providers participating in their insurance plan. So non-participating dentists often feel at a disadvantage in generating new patients, if they fail to participate in PPO networks.

Deficiencies of dental education

Dentists do not have extensive business or insurance knowledge. This makes sense, since, dentists study dentistry, and most dental programs place a greater focus on raw scientific and technical skill. Often, there is little training on the business side of dentistry and the insurance industry that essentially brings patients to the dentists.

What insurance companies do

Insurance companies often take advantage of the gaps in dentists’ business knowledge or more so, the level of time they can devote to it, since their focus is on providing excellent patient care. Hence, dentists may end up earning nearly half what they should from a standard procedure. Truthfully, there is not enough time for doctors to understand the intricacies of the system. However, there are some ways to improve the amount of money obtained from the insurance companies participated with.

Insurance companies also design their plans around the most common procedures. Because these PPOS dictate coverage by procedure, patient case acceptance may be negatively impacted if the procedure is less than fully covered.

PPOs have grown significantly in number and size, and therefore, overestimate the power they have, believing that dentists need their services. Hence, they include unfavorable clauses in contracts such as write-offs for particular procedures that decrease their fees by sometimes up to 30% or 40% less than the standard fee.

Fee schedule negotiation and PPO participation optimization is, therefore, essential to every dentist for adequate compensation going forward. Though the American Dental Association would like to help dentists with these issues, they cannot legally negotiate dentists’ fees. Instead, they provide advice.

How to make PPOs work for you

Here are some of the steps you can take to obtain proper fees due you:

  • Understand your patient base
  • Research and analyze your fee schedules relative to other providers
  • Map out your patient/payor mix
  • Restructure your PPO participation
  • Negotiate higher fee schedules
  • Engage a professional negotiator like PPO Negotiation Solutions

Understand your patient base 

Understand your existing and prospective patient base in your area. Determine the most common PPO among those patients. That will give you a good idea of the PPOs you want to participate with and negotiate the highest fee schedules from. You will also want to actively seek out new patients with this insurance for an optimal claim reimbursement revenue stream.

Research and analyze your fee schedules relative to other Providers 

Analyze the most common procedures you perform. This will help you build a solid understanding of which of these procedures are the most profitable and should be negotiated first with insurance providers. Next, research your fees relative to the average fee charged by all other providers in your area. If you can get this far, at the very least you can determine what you should be charging relative to other providers. Keep in mind most of your competitors are or have already undertaken either PPO negotiation and/or optimization and may already be reaping those benefits.

Map out your patient/ payor mix 

The next step is assessing your fees. Determine exactly where the majority of your fees are generated. Chances are that less than 10% of it will be coming from individuals without insurance. Whereas, more than 90% of a dentist’s revenues come from PPOs. Because it affects a huge portion of revenue, dentists are often reluctant to make even an educated decision about how to participate in PPOs.

Side note: Rising costs are a never-ending dilemma

Operating costs inevitably increase every year. Equipment depreciates and must be replaced with new, more technologically advanced and expensive equipment. Although more and more American’s insurance covers their dental bills, most dentists earn the same amount, or actually, less with inflation, because of the fixed terms in the contracts between practitioners and insurance companies. Therefore, dentists have to find ways to increase revenue and PPOs are the best place to start.

Restructure your PPO Participation

Once you know exactly where your money is coming from, you can drop those plans which are not paying you what is due you and restructure your participation with the PPO’s that pay you more on average. In this manner, you will maximize your revenue and be able to better meet your rising costs.

Negotiate higher fee schedules 

It can be incredibly daunting, but insurance companies will not make an effort to come to you and revise their fees. Insurance companies are businesses, and they care about bringing their costs down and increasing their profit. Hence, it is important, then, to negotiate for the absolute highest fee schedules with the insurance providers you decide to participate with.

When done correctly, a successful negotiation can increase your annual reimbursement revenue up to $100,000. If you have waited five years to do it, you have already lost up to a half a million dollars.

The most important step: Engage a professional negotiator like PPO Negotiation Solutions

The market is changing and dental insurance companies are steadily becoming more and more complex due to layering and rented networks. Furthermore, people no longer depend on a single dentist as they did in the past. This means that today, more than ever, quality care is important to keep patients and gain new ones. To keep your focus on that care, and due to the extensive learning curve and the time investment required; it makes more sense to hire an experienced professional negotiator like PPO Negotiation Solutions for optimal results.

With more than 30 years of experience in the field we have a proven track record and outperform other negotiators by:

  • AUDITING your PPO payor mix & UCR fees relative to competitors
  • DEVELOPING a negotiation plan outlining PPO participation
  • NEGOTIATING the highest rate of reimbursement through cultivated PPO contacts
  • FILING & TRACKING credentialing forms until you are safely “in network”
  • COACHING your team remotely and/or onsite for maximum ongoing results

You can continue to do what you do best…treat patients with confidence and the highest quality care, and let PPO Negotiation Solutions do what we do best…produce at least a 24% increase in your reimbursement revenue, guaranteed! Our service is paid for within the first month after implementation and we provide easy payment terms.

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Your Dental Practice Should Negotiate Insurance Fees

Why negotiate Insurance fees? Insurance companies pay different reimbursement fees to different dentists for the same services. Some dentists are paid as much as 10% more for their services. The difference in the amount dentists receive from insurance companies is based on the ability of the dentist to successfully negotiate insurance reimbursement fees that are at least a little higher than what they had received previously. Some dentists handle negotiations themselves. Others partner with companies that are experts at negotiations. Dentists had been able to simply ask the insurance company for a 5% annual increase and receive it. But those days are over. Today, PPO negotiation is the norm.

The Growth of Preferred Provider Organization Plans

One reason insurance company’s no longer simply give dentists annual payment increases when they request it is because Preferred Provider Organization (PPO)plans have grown in popularity. PPOs now account for more than 85% of the dental plans under which most dentists provide services. As more dentists work under in-network plans, the insurance companies feel less pressure to negotiate. As employers embrace the PPOs as a way to reduce the cost of providing medical and dental care for their employees and increase their bottom line, insurance companies are less willing to negotiate fee increases.

Know Where You Stand

Before dentists begin trying to negotiate for higher fees, they have to know how the fee they currently receive compares to other dentists in their area. The key is to select the right company to conduct large and accurate fee surveys. The information a survey of all the dentists working within the same five-digit zip code provides has a direct impact on the ease and accuracy with which a dentist can compare the fees they charge the insurance company with what other dentists receive. This is very important for a dentist to know to make a strong case for a dental fee increase during POP negotiation.

How Many Insurance Companies are Involved?

In addition to conducting an accurate dental service fee comparison, a dentist that is considering negotiating for better fees should know the number of insurance companies for which they are contractually obligated to provide dental services. That number is often unclear because insurance companies sometimes have contracts with each other that allow them to be able to share both patients and fees. A dentist may have signed an agreement with one insurance company, but the fine print contains an agreement to work with the group of interconnected insurance companies to which they are but one member.

Negotiating Fee Increases Can Be Difficult

Negotiating with insurance companies for a payment fee increase can be difficult and very time consuming. The average dentist does not have the time, training, experience and expertise or PPO contacts to successfully handle this negotiation process. However, if they really want better fees without having to deal with all the headaches and hassles involved in the negotiation process, they can hire companies with teams of professional negotiators to do it for them. These companies often represent large groups of dental offices, so this gives them a powerful advantage and valuable information to use when negotiating.

Getting Adequate Compensation for Dental Services

To ensure they are getting fair and adequate compensation for the dental services they provide, dentists sometimes have to seek out information about the fees other dentists in their service area are receiving. Insurance companies or even other dentists may not be willing to share this important information. However, a survey of dental service fees paid to dentists in their area done by professional researchers can give a dentist the information they need to decide if they are being fairly compensated. Then they can decide if they should contact the insurance companies they signed with to negotiate a fee increase.

Helping Dental Practices to Thrive

When dentists get adequate compensation for the services which they provide, they are able to invest in the best dental equipment and technology, hire excellent staff and provide their patients high quality care. This helps their dental practice to thrive and become a valuable asset to the people and community it serves. This makes the decision to negotiate with the insurance company to get adequate compensation, one that is essential for your practice to thrive and provide the best dental services possible for your patients. It can also make a dramatic improvement in the health and future of a dental practice.

Better Fees Mean Better Dental Services

When dentists and dental practices receive fair compensation for the services that they provide, it enables them to be able to focus on delivering the best possible care for each patient. Most dentists want to be able to feel good about accepting patients from PPO plan providers. Negotiating the right fee structure from the reimbursement plan of the insurance company positively impacts the quality of the services a dentist and dental practice can provide. Reimbursement fees that are too low create a large gap between the real fees and the amount substandard reimbursement forces dentists to write off.

Dentists Are Important to Insurance Companies

Many employers stopped providing dental insurance for their employees during the recent depression and did not add it back when the Great Recession was over. As a result, the insurance companies saw their income reduce significantly and it has not recovered. So, each of the dental offices that remain under contract with and are providing services under the auspices of the insurance companies through PPOs and other plans are important to them. Dental offices have more leverage to negotiate fees than they realize. Dentists should not be afraid to ask for and be willing to negotiate better reimbursement fees.

Reimbursement Fees Are Not Non-Negotiable

It is a myth that insurance reimbursement fees are non-negotiable. This myth has caused many dentists to develop a mindset where they never even consider requesting insurance companies negotiate better rates. Many dentists would be surprised to see how many of the insurance companies they deal with every day are willing to negotiate and increase the reimbursement fees that they pay. Dental practices that are sole proprietorships, as well as those that are members of a group practice,have the power to negotiate with insurance companies to increase the reimbursement fees. They just have to take action.

How To Start Reimbursement Fee Negotiation

Read over the contract you have with the insurance company carefully. Identify where it talks about when and how to request a fee increase. A practice administrator can also provide valuable insight into the fee negotiation process. Negotiating will take some time and patience. Send letters asking for a fee increase to the company’s practice relations department and give them a deadline by which to respond. The letter that you send should contain a copy of the fee schedule for your practice. This provides them with all the data they need. If they won’t negotiate with you, hire a professional.

Resolving the Issue Of Increased Reimbursement Fees

Insurance companies try to make as much money as possible. But it should not be at the expense of hardworking dentists. The insurance companies sometimes use stall tactics to keep dentists from receiving the fee increase they request. In recent years, several major insurance companies have negotiated increases in the reimbursement fees they pay to dentists. But success only happens when dentists request fee increases. Dentists can successfully negotiate insurance reimbursement fee increases. There are companies specializing in negotiating and optimizing dentists’ reimbursement fees. They free the dentist to focus on providing all their patients with the best care possible.

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