The article below is for educational purposes only. Names of carriers have been changed and are not intended to reference actual PPOs. In addition, the fee schedules quoted in the article are fictional.
It started with a call…
Dr. Ryan Buehner from Hershey Dental Associates has been a member of the Dental Cooperative since 2015 and is one of the original five dentists involved in a feasibility study to bring the Dental Cooperative to Pennsylvania. During the COVID forced shutdown in 2020, Dr. Buehner called the Cooperative’s Director of Insurance Fee Maximization, Erica Gordon, to review the preferred carrier (dental insurance) partnerships available through the Cooperative. Some big changes had happened at Hershey Dental Associates through the years, and Dr. Buehner needed to review his contracts and carrier options with a trusted dental insurance expert. He needed some assistance evaluating which carriers he was currently contracted with, whether those were feasible for his practice, along with what other profitable carriers he could potentially start accepting, for which carriers was he eligible for a potential fee increase due to his Dental Cooperative membership, and which carriers he may be considering terminating. There was a lot to unpack and review, but through the process with Erica, this is what Dr. Buehner discovered and presented at the PAGD PEAK meeting in Harrisburg in May 2021.
Sweat the details.
Any carrier will happily send you paperwork to complete, but they will be less helpful to review the terms and small print of your contract. Pay attention to the carrier’s relationships with their partner networks or Payor Lists, also known as Network Partners, Client Lists, Third Party Administrators (TPA), and Lease or Rental Lists. Some things to evaluate when considering accepting or dropping a plan may be:
- Your primary relationship with the carrier, whether you are directly contracted or are “in-network” through a contracted Payor List. Go to dentalcoop.com/reimbursements for a quick tutorial on the different kind of carrier relationships.
- The pros and cons of contracting with a carrier that includes a large Payor List versus contracting directly with multiple individual carriers.
- Understanding and knowing the carriers that will not pick you up as a provider on a Payor List after you have terminated your direct contract with them.
- The time restrictions (30, 90, or 120 days) for being removed from a contracted carrier once you have requested termination.
- The carrier’s re-credentialling schedule regardless of your recent contract effective date.
Focus on the top.
Create a spreadsheet with your top CDT procedural codes, full office fees, and your carriers fees that go with these codes. When talking about your top codes, remember to focus on your top dollar amount total production codes, not your most used codes, which is a subtle but important difference. You may have a code that is used a lot, but in your overall total dollar amount production, may not make the top list. For a typical GP, your top 25 codes represent about 80% of total production, and your top 50 codes about 95%. Your practice management software will easily produce this list for you. So don’t worry too much about the other codes and just focus on your top 25 or 50, especially when requesting a fee review from a carrier. Watch out for related codes that give the plan the option to downgrade to a lower code, for example: composite vs amalgam. In this case, make sure these two codes’ fees are not too far off from each other in case of a downgrade. Remember that less used codes may be increased while your most common codes may not. Just focus on your top codes, and after those, the related codes in case of downgrades.
Let’s take a look at how a PPO plan would typically reimburse for CDT code D0120 Periodic Eval in a few common scenarios for a patient that comes in with a plan from Carrier A. You may be contracted to see this patient under several different signed contracts.
1) Direct contracts
A provider is directly contracted with each of the three carriers below. When a provider is directly contracted with a carrier, they will be reimbursed at that contracted fee schedule. A direct contract typically supersedes any relationships and fee schedules that may exist with carriers listed in a Payor List. Each carrier’s reimbursements are as follows:
2) Carrier listed in only one contracted Payor List
Let’s focus on Carrier A. The provider is not contracted with Carrier A, but is contracted with Carrier B whose Payor List includes Carrier A. In this scenario, the provider would be reimbursed at Carrier B’s rates:
3) Carrier listed in multiple contracted Payor Lists
Back to Carrier A again. The Provider is not contracted with Carrier A, but is contracted with Carrier B and Carrier C whose Payor Lists both includes Carrier A. In this scenario, the provider would typically be reimbursed at the lowest of the contracted rates of the participating Payor Lists. In this case, Carrier C’s rates:
As you can see, understanding the details of the direct contracts your practice signed, especially with the carriers that have a Payor List, will then help when determining by which rate you will get paid. These details will also help you determine which contract to consider terminating or adding to your practice.
The examples show some simple contract differences, and hopefully you can see from our example that treating the same patients’ reimbursements can vary $44 versus $37. As shown in our example, this simple change is a difference of $7 or a 19% increase of payment. Imagine if you had a 19% increase of payment across 80% of your total procedure codes without changing anything else?
Form good PPO habits.
The insurance landscape is constantly shifting, so what may be true today, may not be tomorrow. Carriers come on and off participating Payor Lists without notice which may significantly affect your reimbursements. Here are some good habits to form when working with PPO’s:
- Update your full-fees and codes regularly – Focus on the top 25/50 and related codes. Fee analysis reports and services are helpful in this process.
- Find a reliable contact within a carrier – Though there is always turnover, once you can find a good contact within a carrier, work with them going forward.
- Submit your full-fee schedules to carriers when updated – One of the reasons insurances request the office’s UCR is to help them determine the reasonable and customary fees for the area. Don’t use or submit your contracted fees as your full-fees since this will bring those numbers down.
- Review your reimbursements and call when incorrect – Set up a system to randomly review code reimbursements throughout the year to make sure things have not changed and to make sure you are getting reimbursed at your contracted rates.
- Leverage an advocate and resource like the Dental Cooperative – Whether it’s a Messenger Model like the Cooperative, an IPA (independent practice association), or a consultant, sometimes you may need some help. The Dental Cooperative is unique in our approach and can provide resources to help you evaluate and enhance your relationships and fees that other resources like a consultant may not.
Maximize for you and your patients.
As Dr. Buehner learned in this process, PPO plans and relationships can get complex, but starting with a little knowledge and a resource like the Cooperative at your back can get you much farther and reimbursed at your optimal rates. As a practice owner, you have a lot on your plate, but keeping tabs on how you get reimbursed should always be a priority for profitability.
Ryan Buehner DMD, FAGD, AIAOMT owns Hershey Dental Associates, LLC and has been a member of the PAGD since 2005 and a member of the Dental Cooperative since 2015.
Erica Gordon is the Director of Insurance Fee Maximization for the Dental Cooperative.
For more information about the Dental Cooperative and our Insurance Fee Maximization program, please contact your local Pennsylvania Area Director, Justin Minton at email@example.com or (484) 367-5955.