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PPO Participation, Caution . . . Hazardous Road Conditions Ahead!

Sandi Hudson, Lisa Weber

AADOM, Scottsdale AZ, Sept, 2017

Copyrighted by Unlock The PPO 2017

Sandi Hudson – founder of Unlock the PPO began the company in 2000 to help dentists begin tackling insurance participation and strategy. Sandi works with established practices doing analysis and renegotiations or with fee-for-service offices looking to add PPOs for the first time.

Lisa Weber – co-owner of the company joined Sandi in 2001 to specialize in negotiations and focus on our start up doctors entering into ownership for the first time. Lisa works exclusively with start up offices to create foundational contracting to help launch new practices with the best contracting options.

Goal is to strategically position solo dental practices to compete with corporate owned offices in regards to insurance reimbursements.

We do not represent offices with more than 2 doctors or offices with more than 1 location as a part of our commitment to helping ensure the era of solo practice continues.

We work with solo practices to analyze insurance participation, negotiate where possible with insurance companies, strategize about the best way to participate and map out the

individual dentist’s options for PPO contracting. We don’t advise on claims, coding or billing, we are about stepping back to globally look at the practice’s PPO participation and

help determine the right fit for each doctor at that time.


Direct Contracts vs Shared Networks - What is this mess?


How do you know if you have a direct contract?

A direct contract is one you signed directly with that insurance company. For example, if you are in-network with Aetna by signing a

contract with Aetna, you are directly contracted with Aetna.

A shared network agreement is one you signed with a company where that fee schedule is being used by other insurance companies for

participation and/or payment. For example, if you sign a contract with Guardian and Guardian picks up Aetna through their shared network

agreement then you are in-network with Aetna but you are not directly contracted with them.


Why does it matter (or does it)?

Value to a direct contract:

A more predictable path of participation. You know what you are getting easier than if a shared network is picking up.

If you have an issue there is a rep that has you in their territory that should be able to assist you.

If a patient calls and says “I have ‘X’ insurance, are you in-network?”, your staff’s answer to that is more of a yes-or-no response requiring

less administrative time.If something goes wrong with your contract it’s affecting a smaller,

more easily defined pool of patients.


Why does it matter (or does it)?Value to a Shared Network:

If the fee schedule is attractive, it may be a way to pull in a larger volume of patients at a higher fee schedule

There is no guarantee they have to pick you up or if they do pick up, it may not be all networks.

If there is an error made it make take considerable effort to get it corrected on your part without a designated rep.

Shared network agreements work in both directions so in the same way you can get a large number of companies sometimes at a good schedule, you may find huge

decreases if the shared network agreements pull you down.

Third Party Administrators

What are they? Third party administrators (Connection Dental,

DenteMax, etc.) typically operate as a layer between you and the insurance company. They have agreements with insurance companies so if you take a contract with a third party admin you are agreeing to use that fee schedule

for an entire network of companies.



Added Areas of Caution

With all terminations and opt outs you must follow up!

Do not assume that just because you sent a termination notice that it was processed, be sure to follow up with Provider Relations if needed to verify it was received/processed.

We are seeing a large number of opt outs not being processed with certain third party administrators. If you are not opted out correctly, it is a huge hassle

to follow up and get claims reprocessed, you must be persistent!

Let’s Dive In!A few things to keep in mind of how this discussion may apply to you:

• There is no right or wrong answer, it’s a matter of what is right for you. Your view of the same options may look very different from the person sitting next to you.

• A doctor that is newer with high levels of loans may choose to be more PPO heavy initially whereas an older doctor with more financial freedom may reduce participation. What is the right fit for one at a particular point of practice ownership may look very different for another as life changes.

• Some doctors do not mind insurance, others hate it so the perceived intrusion of PPO contracts looks different to different doctors.

• There is a cost to all aspects of this. Sometimes the cost is with PPO fees, sometimes the cost is staff administrative hassles and sometime the cost is with control (or lack of). Know what you value the most, what is a good use of “cost” for your personality and practice make up and make decisions accordingly.

Let’s Talk Strategy!Dr. John Smith

General Dentist - California

$ 42,000 $ 85,000 $ 5,000 $ 45,000 $ 89,000 $150,000 $100,000 $ 200,000 $ 20,000 $ 90,000 $ 50,000

ADA Code Procedure Description Freq Prod Full fee DELTA PREMIER BCBS 300 CAREINGTON DENTEMAXASSURANT/SUN

LIFEFIRST DENTAL HEALTH PPO AETNA BCBS 200 METLIFE BCBS PPO/100 DELTA PPO

UNITED CONCORD CIGNA ADV UHC

D0120 Periodic oral eval 700 $19,513 $70

D0140 Limited oral eval 180 $5,316 $100

D0150 Comp eval 300 $12,467 $110

D0210 Intraoral- Complete 275 $18,460 $155

D0220 Periapical X-Ray - First 450 $8,623 $30

D0230 Intraoral - Periapical 500 $4,939 $28

D0274 BW - four films 345 $15,108 $85

D1110 Prophy - adult 750 $48,674 $120

D1120 Prophy - child 100 $6,775 $90

D2391 Comp - 1 surf, post 375 $38,385 $250

D2392 Comp - 2 surf, post 325 $43,746 $300

D2393 Comp - 3 surf, post 75 $12,890 $350

D2740 Crown - porc 70 $41,587 $1,450

D2750 Crown - porc/HNM 225 $177,914 $1,425

D2950 Core buildup 150 $19,040 $300

D3320 RCT, bicuspid 25 $10,269 $1,100

D3330 RCT, molar 40 $26,255 $1,200

D4341 SRP 4+teeth 300 $42,609 $300

D4342 Perio Scale 1-3 150 $14,174 $250

D4910 Perio maint 200 $19,695 $175

D6010 Surgical place implant 25 $31,240 $2,500

D6056 Prefab abutment 10 $5,865 $1,000

D6057 Custom abutment 15 $8,170 $1,100

D7210 Extraction surgical 137 $23,283 $325

Ending Collections 70% 69% 67% 58% 57% 56% 55% 55% 53% 45% 44% 43% 42% 39%

Each Delta Production Third party Third party Sun Life Third Direct Production Direct Fee schedule Non-neg Watch Cigna Direct

PPO office assigned admin. admin. recently party contract assigned contract that would and most for other has 2 contract

Analysis has a to lowest Watch for bought admin. with to lowest picks up apply for Delta will companies networks, with

Premier paying downgrade out. Most Aetna paying all Met. most BC be paid that can be sure UHC

schedule option to UCCI Includes relevant still option Pieces of in this case. on this now you know is in

but it's (100). if you par the DHA in Cali. overrides (100). Met are fee downgrade which you place.

virtually with both. network. Watch all available schedule. to this. are in. Blue

irrelevant for shared through TPAs Opt out Shield

if the office downgrade networks but not as needed! is tied to

pars w/ PPO. to UCCI. at this all. Need Tricare moves this in

Most downgrades time. direct for to UCCI in Cali.

to PPO fees. all Met. May 2017.

Note that all numbers and ins comparisons are used only for sample purposes, they are not actual numbers tied to a real practice or insurance company. Our company holds to a strict internal policy of not sharing any confidential data to any other doctor or insurance company. This data is for the purposes of strategy discussion only.

Let’s Talk Strategy!

Sometimes “Strategy” means stopping the downgrades as much as getting increases.

In our sample practice:Many insurance companies with DenteMax and First Dental Health can now downgrade to United Concordia. What’s the Cost?

DenteMax has $85,000 of production at 58% collections that may drop to UCCI at 43%. That 15% loss is $12,750/year in lost profits.First Dental Health has $45,000 of production at 56% collections that may drop to UCCI at 43%. That 13% loss is another $5,850/year in lost profits.

An office could have easily seen a loss of $18,600 a year all due to a contract that appears to have minimal production/impact but the ability for other companies to drop down to it has created large losses.

For offices in Florida and Texas (or any DNOA path for Blue Cross) you need to be extra careful because your states Blue Crosses can be downgraded to the lower fee schedule.

Note that a direct contract does NOT protect you from this drop! Understand the companies you can opt out of and know that you will be automatically opted in unless you opt out!

Can you compete with Corporate Reimbursements?

• About half of our company’s work is with start up practices.

• Most doctors we work with who are opening their first start up practice are currently working as an associate in a group office.

• There are exceptions but, in general, the solo practice can get as good, if not better, fee schedules than corporate offices by doing targeted negotiations and/or by strategic contracting.

Group negotiations assume that PPO negotiations are a commodity like buying bulk supplies or computers. PPO negotiations aren’t valued the same because the same fee schedule does not have equal worth for each dentist. The value to individual PPO negotiations are that the negotiated efforts are for you specifically, not what’s best for a large group.

Lisa and I are two of the only people in the country who own a negotiations company yet work directly with all of our clients. Our information is based on what we personally see from a unique perspective.

Delta ChangesYou’ve either been hit or will be. Prepare!

Delta contracting changes are happening but vary on a state by state basis:

1. Some states (example California) are grandfathering in Premier-only providers but no new Premier providers are allowed.

2. Some states (example Arizona) are allowing doctors to remain Delta Premier-only as long as they take no other PPOs. Once they take another PPO (Cigna, Guardian, etc.) then they are dropped to the PPO schedule with Delta.

3. Some states (example Washington) dropped fees across the board for Premier-only providers.

4. Some states (example Massachusetts) are completely eliminating Premier and doctors who had been Premier-only must become out of network totally or drop to PPO.

5. Some states (example Michigan) allow older Delta contracts to keep their “Legacy” fees but not for new dentists.


Who EXACTLY do you have contracts with?

See attached list for helpful phone list if you need to have your staff reach out when you get home.

Do you know if you are Delta Premier and PPO?Do you know if you are Cigna DPPO or Advantage?

Do you know EVERY third party administrator you may have signed up for?

How long has it been since your last increase?Most negotiable companies will allow you to request a negotiation a

minimum of 24 months since your last increase.

Do the fees you are getting paid match your agreed upon schedules?


Some Action ItemsChange your frame of reference for insurance contracting

There are no easy answers any longer with contracting. If you operate afraid to ever go out of network with any contract or company you will eventually find yourself getting paid on the lowest paying fee schedule.

Know what bottom line you can accept for your business model with your contracts. If a contract is no longer workable for you, make the move to

drop it. Do it knowing how shared network agreements work so that you understand the cases when a shared network MAY pick you back up, but

that your decision is made independently of that in case they do not. Keep contracts in place that may work to your advantage later, eliminate the ones

that are doing nothing but hurting you.

unlocktheppo.com 855-327-9125 · unlocktheppo.com 855-327-9125 ppo participation, caution . . ....

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