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Dental Insurance 101

Contracting & Negotiating with PPOs

If you chose to be an in-network (PPO) provider, it is critical to negotiate reasonable fees for your participation from the start. Negotiate initial contract fees and follow contract dates for re-negotiation opportunities. Most contracts have 18 to 24-month terms. Please note this negotiation process can take up to 90 days. Once you have accepted the contract and filed for credentialing, it can take another 3 weeks to gain in-network status, so start earlier than later. There are some key strategies when negotiating fees with insurance companies:

 

  1. Your current fees – Order the NDAS fee disc from Burkhart (through your Account Manager). To set your UCR fees as a new general practitioner, start them in the 80th percentile for your geographical area. If your UCR fee schedule is set too low for your area, negotiating will be challenging. It is important to maintain your bargaining power.
  2. Research the plans offered by major employers within your targeted patient area. Consider schools, hospitals, federal and state offices, and large employers who may have a national footprint. Call the human resources department to inquire who holds the contract for their dental benefits.
  3. Research plans widely accepted by the dental community in your area. Ask your colleagues and fellow study club members about the insurance landscape. The more widely accepted a plan is, the more pressure you will feel to gain in-network status. Potential patients in your community will have access to a variety of providers in those situations.
  4. Contact each of the PPO plans you would like to consider. Ask to speak with a professional relations representative or in-network recruiter. Request a copy of the participating provider contract, processing policies, and in-network fee schedule.
  5. Keep an organized folder for each insurance plan you are considering. As you accept a network assignment, move the contracts and fee schedule to a binder separated by a tab for each insurance carrier. Note the eligibility date for potential re-negotiation in a prominent place.
  6. Determine your Top 30 codes based on production for the practice. For most dental practices, 30 codes will account for 90% of your billable production. Determine the top 30 codes by running a Report by Procedure code report (if possible from the practice you are in currently), or get a general listing of these from Burkhart’s Practice Support Team.
  7. Compare the contract fees sent from each provider with your UCR fees. Which come closest to your UCR fees AND afford you the best marketing opportunity for new patients? If possible, prepare a weighted average write-off by multiplying each code and fee by the frequency the code was used in your office for the last 12 months.
  8. Determine your negotiating leverage.
    • Understand the geographic location and the saturation of dentists in your area.
    • Is there a specialty offered or a unique target market?
    • Availability in hours offered.
    • The availability of teledentistry. Many carriers use teledentistry as a selling benefit for additional employer recruitment.
    • Ask each plan under consideration if they have a “co-lease agreement” or “network share arrangement/agreement” with any other carriers. For example, a plan like Aetna might share fee schedules with another well-known carrier like Principal.
    • Electronic claim processing capability.
    • EFT enabled for receipt of claims payments.
    • Use of online portals for eligibility and pre-authorization.
    • Plan to negotiate with each network share opportunity individually. Keep in mind, you can always opt-out of a network share arrangement. You must submit a letter with your signed contract stating your opt-out preference.
  9. Initiate negotiations through email with the network recruiter.
    • Summarize any phone conversation in an email to create a written verification of your discussion.
    • Ask for a custom fee schedule. Let the network know you would like a custom fee schedule based on 30 codes. (The same 30 codes you identified previously.)
    • Request a response to your proposal within 72 hours.
    • Be prepared – some insurance carriers simply do not negotiate. Everyone in the same geographic area operates under the same fee schedule. Other plans will offer “tiered” schedules – if you don’t accept the first one, they send a second slightly higher schedule. You will benefit the most from a custom schedule based on your 30 codes.
  10. Review the fees offered, and do not hesitate to send in a counter-proposal (if you never ask, the answer is always no).
  11. Once fees are accepted, keep a list of the accepted contract terms and copies of all final fee schedules. Audit claims to make sure your agreed-on fee schedule is honored. Create a healthy protocol to audit a dozen claims on a semi-annual basis.

 

A few other notes:

  • The dentist should initiate the negotiation process. Statistically, the dentist has a much greater chance of negotiating favorable fees.
  • Consider the possibility of staying out-of-network. Accepting an inferior fee schedule will force a systems change in your practice. You will need to process more patients in less time. An assisted hygiene schedule, where the hygienist treats six patients every four hours, is an example of altering a system to treat more patients under a lower fee contract.
  • Be persistent but polite during your process and stay organized so you can compare fees offered against your Top 30 codes.

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