Source: https://unlocktheppo.com/author/sandi/
Timestamp: 2019-04-24 23:53:03+00:00

Document:
United Concordia added Lincoln and Ameritas to their shared network agreement. An opt-out is available for these but an office participating with UCCI will automatically be opted in without an opt-out letter being submitted. A direct contract with Ameritas does NOT override UCCI. Principal and First Dental Health were already added to the UCCI shared network agreement at the end of 2016.
Connection Dental and Cigna ended their shared network agreement. Cigna Advantage requires a direct contract. Other third-party administrators continue to have shared network agreements with the Cigna DPPO network.
United Healthcare and Guardian added a new shared network agreement in Dec 2017. A direct contract continues to override.
Maverest was bought out by Zelis. Maverest fee schedules already in place were allowed to remain but Maverest no longer exists as its own entity, it is being managed by Zelis.
Careington Platinum Specialists did not have access to MetLife (PDP+) in the past but a trial sampling of some offices has started to occur in December 2017. At this time it’s a limited number of offices being affected.
Colorado joins the majority of states passing laws prohibiting the insurance companies from forcing dentists to honor PPO fees for non-covered services. SB 190 was passed effective 8/9/17. Read about the law here.
Delta continues to be a concern for dentists as restrictions expand on the PPO vs Premier contracting options on a state by state basis. Do a careful evaluation of your practice make up to know what amount of your practice is tied to Delta, know what your state’s options are and how to take both a short and long-term view of how Delta fits into your practice.
Recredentialing packets are normally received from each insurance company about every 2 years. These don’t affect your insurance negotiations, they are information updates required to keep your current contracts in good standing. Be especially careful now with recredentialing! If you do not return recredentialing by the due date you will be bumped out of network and, if that happens, you may not get your previous fee schedule reinstated. When you get recredentialing requests make sure you not only return them, but that you also verify they were processed by having your staff call to confirm. Even if you sent the requested information, if the insurance company doesn’t show it as logged you’ll still be termed and some companies are using third parties (Humana using Medservant for example) where it can be difficult to get resolution if you get termed. Finally, with recredentialing be sure you read your paperwork to make sure you are not voluntarily giving up your ability to charge full fees for non-covered services or other changes that may be slid in if you do not read carefully.
There was a recent newsletter that set off widespread panic with an announcement that insurance companies/TPAs would stop allowing out of network benefits in 2018. Employers may choose to limit out of network coverage as they always have but there was no massive policy change in 2018 that wasn’t already in place before. A caution that, as more consultants attempt to move into this hot topic of insurance contracting, there is a good deal of misinformation being generated. Do your due diligence in confirming information directly with the carrier before assuming what you read or hear is accurate. Some information being spread is just plain false.
For those offices who are contracted with PPOs and plan to continue to remain so, we absolutely believe the solo dentist can still negotiate and strategize contracts as well as, and usually better than, corporate offices. The complexity of optimizing contracting makes it much harder to do for larger offices. So much so that we don’t think it is possible to do it on a larger scale the same way as a solo practitioner can do. We’ve been approached from every angle to do larger group and corporate negotiations and have always declined because what we do for solo dentists can’t be done on a larger scale with the same, customized results. While there are continued PPO challenges ahead, we still see solo practices as very competitive in the PPO negotiations area.
Best wishes to all of our dental friends as we wrap up 2017 and hope you all have a blessed 2018.
We’ve posted extensively about the differences between direct PPO contracts and third party administrators (link to DT article here for more information: https://www.dentaltown.com/Images/Dentaltown/magimages/0614/DTJun14pg22.pdf ). In the past, direct contracts with a company would override third party administrators so the strategy has been to use direct contracts when the rates are higher and when using a third party admin, use it only when a higher paying direct contract was not available. We’ve started seeing cases where payments were starting to shift downward, especially when more than one shared network agreement was in place so we knew the trend would be where insurance companies would figure out how to start paying on the lower paying option.
We just got confirmation for the first time in writing with a company (that will remain unnamed) that a shared network agreement can take priority over a direct contract with them based on which fee schedules gives the best value to the member.
This is a huge game changer because it’s the first written confirmation we’ve had of what we knew would be coming – that you need to assume that your lowest paying fee schedule could begin dictating fees with other companies regardless of if you have a direct contract in place. We are not seeing this industry wide yet but assume it’s coming and start strategically planning.
If your staff is not watching EOBs continually and making sure that the fees paid are based on the contract you signed, chances are you are getting payments downgraded and not even realizing it. We see offices all the time that are just entering payments and not watching to be sure that fees are not getting downgraded. This is something dentists need to be making number one priority for whoever enters payments. The days of just entering payments without having a clear understanding of fee schedules, contracting and shared network agreements are over. Most companies have Opt Out options where you can play the game still to shift to higher paying options but you have to put those into place yourself for your benefit or assume the insurance companies will start to shift you downward to what’s best for their benefit.
Join us for an Alaskan Cruise and CE-August 7-14, 2015!
August 7, 2015 is a 4 hour class in Vancouver, Canada by Drs Murph/Fletcher. The lectures will include How to use a 301 elevator, How to use a Dr. Murph Crane Pick, How to Elevate Flaps, and Surgical extraction techniques. The class will be 8am until 12 noon at the Holiday Inn Vancouver Center 711 West Broadway 604-707-1939. Tuition for this class is $600.
Contact Dr. Murph 843-488-4357 and register for the class. Tuition is $2499 for 20 hours of CE. If you only want to do the lecture in Vancouver or only do the lecture on ship for extractions or only do the lecture on ship for insurance participation/non-participation or only do the lecture on ship for restorative dentistry or only do the lecture in Anchorage, the tuition for each lecture separately is $600 and each is 4 hours of CE separately.
On August 8, 2015 there will be a 4 hour lecture on “How to Handle Complications that Occur after you have Removed a Tooth”. This lecture will be 8am until noon and will cover staying calm with nerve damage, Sinus perforations, dry sockets, boney spicules, and more. This is going to be a casual discussion of topics and we want the intimate group to ask lots of questions about complications that they have encountered or are scared of occurring. Drs Murph & Fletcher.
On August 13, 2015 Lisa Weber, a partner in Unlock The PPO will give a 4 hour lecture on Tactical Insurance Participation/Non Participation. Each practice attendee will receive a custom insurance demographic report and a snapshot analysis of their own practice data for evaluation (if requested). Third Party Administrator/Shared network dynamics will be of particular focus. Take control of participation rather than having PPO’s control you! The lecture tuition for this class is $600. This lecture will be on board the ship from 1pm to 5pm (we’ll be sailing past the glaciers just before lunch this day so get ready for an incredible sight! You can contact Lisa for more details at lisa@unlocktheppo.com. Their company website is www.unlocktheppo.com.
Cruise is Royal Caribbean “Radiance of the Seas” and leaves Vancouver on Friday August 7, 2015 about 5pm going to Seward, Alaska arriving on Friday August 14, 2015 and deboarding about 10am.
Go to www.danquevedo.cruiseshipcenters.com/contest Fill out the information asked for, click “Continue” at the bottom, and you will be entered into a drawing for a free Caribbean cruise.
The above Hotel Stays are just suggestions. You could come to Vancouver and tour a few days before (lecture will be 8am to 12 noon on August 7 in the Hotel). Indicate your desire on the Client Information sheet mentioned above and Dan will take care of it for you. In Vancouver, we will check out and go to the cruise ship after lecture. When we get off the ship in Seward you will travel by bus about 2 hours to Anchorage and arrive around 1pm and check into the hotel (lecture will be 5pm to 9pm). You could just drop your bags off at the front desk and do the lecture and then fly home on a red-eye flight. Many of the flights out of Anchorage going east leave between mid-night and 3am so you may want to check on flight times before you make hotel reservations.
I’d strongly recommend you check with Dan Qeuvedo as soon as possible because the pre-booked blocks of rooms have already been grabbed by attendees but there are other rooms available! I’m hoping to meet many fellow Townies-Alaskan Bound!
There are a few things that we’ve found as we’ve had the privilege to work with a lot of startups and I wanted to start a thread just to address those initial challenges. We hope to prompt doctors who are about to begin on this journey to step back and think about their individual situations and do a bit of homework and self-evaluation before they move forward.
Undervaluing your treatment before you even open- Dentists who come to us with current employment in either a corporate office or a high volume Medicaid office typically either want very little participation based on the fees they’ve seen or they think there is no other way to success than taking every carrier known to man. Neither is true. There is a reason that I typically do not want dentists to see what a carrier might propose for an initial fee schedule before they set their cash fees. Too often, that $580 crown you’ve seen at your associateship makes you undervalue the treatment you’re going to provide at your new office and you set your cash fees too low from the very start. Pedodontists are hands-down the group who typically undervalue their treatment the most, likely because they are more likely to be associating in an office with high Medicaid enrollment. STOP THAT. I ask Startups to step back and set their cash fees like they are a completely FFS practice and that is a fee they are comfortable with for a particular procedure if they are going to be seeing a patient who has no insurance at all. If I can get 100% of their full fee from a carrier it’s not because I did an awesome job but because they’re not charging enough, and I’ll tell them that every time.
Starting too late- It’s very easy to be absorbed in the process of finding a site, getting a builder, figuring out what kind of chairs and PMS you want to use, and then realizing 60 days before opening that you have not even thought about insurance. Reality check- Delta is taking on average 4 months in Texas, California, and Georgia if you are already IN network to be added at your new location. Delta is likely to be your #1 carrier revenue source, in net or out. If you don’t par, you have to collect in full from your patient at time of service. Talk about a roadblock in your way when you’ve spent thousands to market to these same people to call you before you open and the answer when they call is “Well, we’re going to be in network but we aren’t, but if you pay us in full, we’ll file the claim and the check will go to you”. This conversation happens every day. If you’re intending to be out of net, that’s a crucial conversation that your team needs to be able to master (and if they can’t they shouldn’t work for you) but if you’re intending to be in network, you’re beginning your conversation with these patients in a position you don’t need to be. Most carriers that are negotiable take a good 30 days just for negotiations, after you’ve set your top codes and fees and another 90 days in credentialing. Plan accordingly. If you rush, your fee schedules that will form the foundation of your insurance collections will reflect that.
Signing with everything because you’re afraid if you don’t, the patients will not find you. Look up your ultimate zipcode like a patient would and see how many other providers are in net in your 5 and 10 mile radius. If there are more than 20, they are not likely to find you that way anyway. They will see your signage, see your office, receive your marketing, or hear about you from someone who heard about you and then log in to see if you’re in their network. What is that conversation going to be when they call? You must pair your participation with other marketing because passively waiting for the listings to send people to you doesn’t work in a saturated environment and most environments are now relatively saturated.
Participate if it benefits you, not because it’s a rite of passage. It’s only a benefit to you if what you receive outweighs what you lose and you need to think in the long-term, not just an immediate need to fill a chair.
Don’t burn your bridges- I know you may want to bail on that associateship as soon as you can, but the steady and predictable income from an associateship position will give you breathing room so that you are more likely to make decisions that will benefit you for the short term and for the long term. It’s a far better feeling to find that you’re busy enough that you can drop days at that associateship faster than expected than the feeling that is associated with feeling you’ve got to go work somewhere for any paycheck at all, just to make payroll as you begin to develop your own practice. About 95% of our startups wish to keep their future plans confidential as they look at opening a solo practice and carriers are used to that request. Give your employer notice if you can because it’s not just the right thing to do, it also preserves your ability to have an additional income as you focus on your new practice and it can be a positive for both sides.
Hiring a FD– Don’t wait until 1 week before opening to hire a FD and then be surprised that the person you hire (with no dental experience) is having a difficult time entering insurance information, estimating copayments, using your new whiz-bang PMS. Your understanding the software and having played with it in the trial version does not mean that your FD can do the same in an environment where they have calls coming in, a schedule to fill, and a dentist standing over their shoulder looking at what they’re doing. If you hire someone with no dental insurance experience, that’s what you get. It’s not brain surgery but it is not intuitive. They may have had experience with your PMS…they may have been trained by someone who was trained by someone who figured it out on the day the previous someone quit and none of those someone’s actually was trained well. That person may bring some awesomely bad habits to your practice because she doesn’t know any different. If you do complex dentistry, understand that it also comes with complex claims. If you hire someone who has LOADS of experience, make sure to do the PMS training with them in advance of your opening and you may find that the resume was inflated. A lot. I’m actually a fan of hiring people and teaching them the way you want them to do things. If you don’t know how to file claims or use your PMS, you can’t teach them so you need to make sure you budget enough to hire someone from the PMS company you’ve signed on with who can. Your data is perfect before you open. Everything that can happen to totally screw it up begins to happen on Day 1. Know how to navigate your PMS well and where to find everything. Do not allow yourself to be hostage to any single employee or you’ll make allowances for the person you want to let go, simply because you don’t know where to find things. Remember. They came to see you, not the FD, no matter how awesome she is…promise.
Teach your FD , hygiene and assistant your own language- Review the procedures out loud that you’ll do in the same way you will explain it to your patients. Ideally they echo and reinforce you and if they have questions about what you’ve just said, assume your patients will as well so you need to rephrase so that everyone understands. Your FD will not see red flags in treatment plans or estimates if she has no clue what the procedures are. Teach from the beginning in Hop on Pop language and just like you would talk to your patient. Do this even if they have experience because you’d be amazed at how some have always misunderstood a procedure and parroted that misunderstanding to a patient. Bad communication is a really good source of lousy copayment estimates.
Not learning from mistakes– Balances that a carrier didn’t pay or a patient didn’t pay are not reasons to berate your FD in the first week of their employment. Nope. If there are balances, you’ve either not hired well or not trained well. It’s your fault, sorry. Balances to me are going to happen and are an opportunity to step back, figure out how it happened and put into place systems to keep it from happening again. There are reasons PMS programs have note sections in the employer and carrier fields. Use them. Each day doesn’t have to be Groundhog Day. You can take a balance, and turn it into a template to understand how that carrier will behave when it gets claims for other patients and prevent surprises in the future. A balance that is unexpected that doesn’t generate action to prevent it from happening in the future is a wasted opportunity and also more likely to be the reason a patient leaves you than they’d leave you if you hurt them. They are expecting you to hurt them and are pleasantly surprised when you don’t. They are not expecting a balance of $75 in the mail and will leave you because of it. A dentist once told me that he was making his FD go over all claims with him first to make sure they were correct. I asked him if he knew what it should look like and he admitted he didn’t. This startup specialist is on his 3rd FD in the first year of his practice because they’ve left. None of them received training by their PMS. From personal experience, hiring, firing, and replacing is a very expensive process and it’s far better to get the right person and give them the right tools from the start. Check out Sandy Pardue’s threads and do nothing but read. Please.
Pay attention to the Red Flags and share your experiences because this generation of startups is building on each of your successes and are being cautioned in advance on other challenges by those who have gone down the same path. Thanks to DentalTown (visit TownieCentral.com) you honestly don’t have to go it alone because there are loads of resources here if you just search. Plan ahead, give yourself time, and give yourself credit for being someone who a patient would want to see PPO or not, and the patience to deliberately focus on making your dream come true. It will.
Below is information from a post on DentalTown provided by Jason Wood, a dental attorney very familiar with the corporate influence in dentistry, and like us, a proponent of advocating for the solo dentist. We have seen a very different dynamic in PPO rates in Texas in the recent years, much due to the influx of corporate involvement. Below is information we encourage Texas dentists to read and take action on but also encourage all dentists to stay educated about so that you can battle nationally as these opportunities present themselves.
Do you want the ability to combat corporate dentistry? Here is your greatest chance to do so. PLEASE NOTE, while this will impact the State of Texas the reverberations will be felt throughout the entire United States and is this industry’s greatest chance to fight back against the hedge funds, venture capitalists and stockholders who are threatening the very well being of this industry. The Dental Board of Texas should be applauded for their efforts in seeing through the false arguments that corporate dental companies use by claiming they serve the poor and underserved populations and are providing “access to care” to millions of Americans. The reality is, as we all know much more sinister; they prey upon the uninformed and neediest of the population and encourage the overtreatment of the poor and middle class and place them in financial hardship with their credit policies.
I invite all Texas dentists that have been employees of corporate chains, and all dentists that have seen the work performed by corporate chains, to appear at a public hearing regarding a rule change that will effectively BAR non-dentist companies from owning dental practices in the State of Texas.
The hearing can be found at the link above. I implore all to attend as the corporate chains will have their lobbyists and attorneys there. We need rationale, non-emotional, scientific arguments to be presented at this hearing. The Dental Board is behind this, however the corporate players are spending MILLIONS trying to defeat this and are, I am sure, speaking to as many politicians as possible regarding this. You will need to be committed and organized to see this law get passed.
Below is the language of the proposed change in the law. You can see that it effectively terminates the ability for the corporate chains to make money off of this. Please spend some time reading this, and agreeing to take part. I encourage you to repost this on other forums and sites so that this gets maximum exposure in the next week. You have one week to rally the troops to what may end up being a pivotal battle for the heart and soul of this great profession!
The State Board of Dental Examiners (Board) proposes the repeal of 22 TAC §108.70, concerning improper influence on professional judgment.
The agency seeks to repeal §108.70 and replace it with proposed new §108.70 which clarifies the permissible contractual agreements or arrangements between dentists and non-dentists.
Julie Hildebrand, Executive Director, has determined that for the first five-year period the proposed repeal is in effect, the repealed rule will not have foreseeable implications relating to cost or revenue of state or local government.
Ms. Hildebrand has also determined that for the first five-year period the proposed repeal is in effect, the repealed rule will ensure the protection of public health and safety. Ms. Hildebrand has determined that for the first five-year period the proposed repeal is in effect, the repealed rule will not have foreseeable economic costs to persons or small businesses who are required to comply with the rule. There is no foreseeable impact on employment in any regional area where the repealed rule is enforced or administered.
Comments on the proposed repeal may be submitted to Simone Salloum, Assistant General Counsel, 333 Guadalupe, Suite 3-800, Austin, Texas 78732, Fax (512) 463-7452, rulecomments@tsbde.texas.gov, no later than 30 days from the date that the proposed rule is published in the Texas Register.
The repeal is proposed under Texas Occupations Code §254.001(a), which gives the Board authority to adopt rules necessary to perform its duties and ensure compliance with state laws relating to the practice of dentistry to protect the public health and safety.
No other statutes, articles, or codes are affected by the proposed repeal.
§108.70.Improper Influence on Professional Judgment.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency’s legal authority to adopt.
Filed with the Office of the Secretary of State on August 25, 2014.
The State Board of Dental Examiners (Board) proposes new 22 TAC §108.70, concerning contracts, agreements, and arrangements with licensed dentists.
This proposed new rule provides guidance concerning contracts, agreements, or arrangements, between licensed dentists and unlicensed persons.
Julie Hildebrand, Executive Director, has determined that for the first five-year period the proposed new rule is in effect enforcing or administering the rule will not have foreseeable implications relating to cost or revenue of state or local government.
Ms. Hildebrand has also determined that for the first five-year period the proposed new rule is in effect enforcing or administering the rule will ensure the protection of public health and safety. Ms. Hildebrand has determined that for the first five-year period the proposed new rule is in effect, enforcing or administering the rule will not have foreseeable economic costs to persons or small businesses who are required to comply with the rule. There is no foreseeable impact on employment in any regional area where the new rule is enforced or administered.
Comments on the proposed new rule may be submitted to Simone Salloum, Assistant General Counsel, 333 Guadalupe, Suite 3-800, Austin, Texas 78732, Fax (512) 463-7452, rulecomments@tsbde.texas.gov, no later than 30 days from the date that the proposed rule is published in the Texas Register.
The new rule is proposed under Texas Occupations Code §254.001(a), which gives the Board authority to adopt rules necessary to perform its duties and ensure compliance with state laws relating to the practice of dentistry to protect the public health and safety.
No other statutes, articles, or codes are affected by the proposed new rule.
§108.70.Contracts, Agreements, and Arrangements with Licensed Dentists.
(1) For purposes of this section, “dentist” includes a Texas-licensed dentist, dental professional corporation, or other entity owned by one or more Texas-licensed dentists that provide dental services.
(2) For purposes of this section, “dental practice” or “dental office” includes patient charts, equipment, supplies, goodwill of the practice, and accounts receivable.
(b) A person who is not a Texas-licensed dentist violates §251.003(a)(4) of the Dental Practice Act, by engaging in the practice of dentistry if the person owns, maintains, or operates an office or place of business in which the person employs or engages under any type of contract another person to practice dentistry.
(c) A person who is not a Texas-licensed dentist violates §251.003(a)(9) of the Dental Practice Act by engaging in the practice of dentistry if the person controls, influences, attempts to control or influence, or otherwise interferes with a dentist’s independent professional judgment regarding the diagnosis or treatment of a dental disease, disorder, or physical condition.
(7) penalizing a dentist for reporting violations of a law regulating the practice of dentistry.
(e) Licensees who enter into the contracts, agreements, or arrangements described in section (d) are subject to disciplinary action pursuant to §263.002(a)(8) of the Dental Practice Act.
Insurance Recredentialing Issues – Beware!
Requests for recredentialing with insurance companies is not something new however you will probably notice more requests coming your way. As part of some of the new healthcare changes, requests will be coming more regularly and we strongly advise you give your office staff a heads up to watch for these. Recredentialing requests are not tied to negotiations or changes in fee schedules, they are information requests to keep your current contract in good standing. Contracted doctors MUST return these or you can/will get bumped out of network. If you get bumped out of network, getting back in isn’t as easy as just responding later, you may have to start all over getting recredentialed and it can take months to get pulled back in-network.
We have had some recent major issues with doctors returning recredentialing information, having proof that they returned it, and still getting moved out of network. Do not just return recredentialing paperwork by mail and check it off your list. Get confirmation in writing that it was received, either by email confirmation or by certified mail where someone from the insurance company must sign for it. Keep a copy of the signed receipt in case it’s needed later.
Also note that if you are in a state where you participate with Delta Premier and that state no longer allows for new contracts to be Premier only it is especially important you return and verify recredentialing information. If you get bumped out of the Premier network and new contracts are requiring PPO participation you will no longer be able to get your Premier status back once lost. In states where this applies it’s about a $100,000 mistake for most offices so do not allow this to be overlooked by your front office staff.
If you are contracted with a third party administrator (Connection Dental, DenteMax, etc.) you could have dozens of companies being pulled in-network through that single contract. If you get bumped out of network with that third party administrator you then find yourself out of network with all of the companies falling under their umbrella. Connection Dental, for example, is taking 4-5 months to process effective dates with applications in many areas right now so getting back in-network can be a lengthy process. If you get termed from a third party administrator like Connection Dental, even if you sent the paperwork back in time, if they make an error and term you it may not keep you from having a gap in participation with any carrier you are in network with. We’ve recently seen several real world examples of this and it’s impacted critical carriers for those doctors. In case of an error, just because the third party contract itself gets resolved doesn’t mean all the individual carriers get resolved at the same time. If claims were processed incorrectly due to a lapse in participation from a third party error there is no guarantee the individual carriers will reprocess the claims.
Also note that recredentialing requests do not necessarily coincide with dates of when you signed your most contract. Let’s say, for example, that you have a relatively new practice that just opened 6 months ago and you recently signed a new contract to participate with an insurance company. You may receive a notice for recredentialing that indicates every 3 years they need to recredential doctors and you are due. You may assume it is in error because you know your contract is only 6 months old. Keep in mind that you may have been showing up in-network as an associate or at another location prior to the new contract you signed for your new office. Your initial full credentialing may have been tied to another office with a previous date so the clock for recredentialing may not have started with your new office’s contract. This could make you due for recredentialing even though your current contract has been in place for a short time.
In short, when your office gets a notice to recredential do not ignore it! Regardless of if you think you are due or not, you must return it or you should plan on being moved out of network. And always get verification in writing that it has been received!
If you’re reading this, congratulations are probably in order because you are headed towards owning your own practice! About 40% of our business is working with start up practices who are planning ahead to open their new offices and are attempting to analyze which insurance plans to accept. The number one thing to remember is to plan ahead 120 days or more whenever possible in order to allow yourself enough time to make unrushed decisions about participation. Often we get calls from dentists who are opening in a month and want to be in-network with all companies at their opening date. Not only is that not possible, dentists in this position end up either having to wait for a couple of months to get contracted or they sacrifice potentially higher fee schedules in order to get in-network faster. It’s almost always worth waiting an extra month or two to be in-network than agree to a substandard fee schedule just to get in-network quickly. The negotiations process takes 90-120 days with many companies so the farther ahead you plan, the more options you create for yourself. Whether you hire out for insurance credentialing/negotiations or do it yourself, here’s a list of the process we go through which may be helpful for you to consider as you move towards your opening date.
Do a demographic analysis of the area by researching who the top employers are and which insurance companies are tied to those employers. This will allow you to see which insurance companies may be more important to consider participation with depending on your particular market. There’s no quick and easy way to do this, but with a combination of online research coupled with calls to HR departments you can verify which insurance companies are affiliated with each employer.
Get a third party fee analysis and set your fee schedule. We include this for our clients but any individual dentist an order a third party fee analysis from various sources. These can be obtained for less than $200 and we encourage you not to take a short cut here. Don’t be tempted to take your current associate fee schedule or ask a peer for theirs to copy. If they haven’t rebalanced their fees appropriately you’re just borrowing a poor fee schedule and applying it to your new practice. How you set your fees is VERY important for fee schedule negotiations. If you set your fees skewed too low it can impact the offers from the insurance companies. By the same token, if your fees are off-the-charts high the insurance companies may assume you are artificially inflating your fees for the purposes of negotiations. You want to choose fees that you will be comfortable implementing for your cash paying patients. Do not play games and try to negotiate high fees up front only to really discount your UCR fees when you open. Insurance companies are now comparing fees submitted for negotiations with actual claims your office submits upon opening to see if they match. If they do not, it can impact your future negotiations ability.
Choose your top (about) 30 fee codes to focus negotiations on. About 90% of a general dentist’s production comes from about 30 fee codes, fewer for specialists. Don’t obsess about getting higher fees on codes that you’re unlikely to utilize, get very serious about the fees on your top codes. If your state has passed the law to allow you to charge your full fee for non-covered services, keep that in mind as well. You don’t want to waste one of your limited negotiations if it’s a code you can probably charge your full fee for anyway. Once you go to the reps to negotiate you want your fees and your code selection to be FINAL. Do not start changing fees or the codes you want negotiated after you’ve started the process or you’ll slow things down or even cause the rep to start over. This creates delays that most startups can’t afford to have.
Even if you are an associate at another office and are in-network there, in general you do NOT want to do an “add a location” if the company negotiates fee schedules. Usually you will be able to get a better offer doing a fresh negotiation based on the top fee codes you’ve chosen as most important. Remember that your new office fee schedules will be tied to your tax ID number and are not a reflection of your associate office. The exception to this rule is United Concordia which follows the dentist’s license rather than TIN. Whatever initial contract you sign will not be negotiable again for 18-24 months in most cases so you want to be sure you have structured your initial contracts with your new TIN correctly from the beginning because it will be a couple of years before you can usually renegotiate.
If you are an associate at a corporate office currently, do NOT assume that they have negotiated a better fee schedule than you, as a solo doctor, can obtain. Corporate and individual negotiations are different departments and negotiating as an individual allows you to focus on the codes that are most important to you personally.
A very important component of insurance participation now is understanding the difference between direct contracts and contracting with shared/third party administrators. You can be paid differently on the same patients oftentimes depending on how you’ve chosen to contract. In general, if you are directly contracted with an insurance company those fees take priority. If you are contracted with a third party administrator (such as Connection Dental, DenteMax, Maverest, etc.) then they will pick up a large list of companies (except the ones you already have a direct contract with). There are pros and cons to third party administrators, the main issue is to be sure you understand exactly what you are signing up for. They can give you broad exposure to lots of insurance companies however you want to understand how they work and be in control of the process.
Be aware that there is little turnover with reps in the insurance industry. The reps you work with now are likely to still be there in a couple of years when it’s time to renegotiate. Know that “playing hardball” is not about being rude or demanding, it’s about having a very clear understanding of your market and getting the best offer available that fits your particular procedure code mix.
Have a good idea of what you would consider an acceptable fee schedule before you begin the process. We often get asked what is a “good” amount of write offs for a fee schedule. Know that usually a 20% write off is going to be a minimum that can be expected and that’s in less competitive parts of the country. On rare occasions we’ll see lower write offs in an area that is less saturated or for specialists but in general, if you are not going to accept an offer that has a 20% or more write off then you should consider pursuing a more fee-for-service business model and allocate more towards external marketing instead. Some areas can expect to have write offs in the 35-50% range as standard. In general the Midwest is typically less saturated while some of the more saturated/harder to negotiate areas are currently California, Florida, New Jersey, Ohio, Pennsylvannia and some other specific cities such as the Chicago area.
Be aware that it’s taking far longer to get in-network with some major carriers, even if you are already credentialed at another location. For example, Delta in Texas and Georgia are taking a very long time to process and are requiring additional follow up. There are bottlenecks with certain companies in certain areas so be sure to regularly follow up to get your final effective dates.
A phone number (which can be a Google number initially and then transferred to a permanent number later if needed).
Know that there will be staggered effective dates and some may trail your opening date. That’s ok, you’re off to a great start and the choice to wait for the highest options is always worth a few weeks delay. You will have set your foundation well for the long term!
One issue we’ve been passionate about is dentists working to pass laws guaranteeing that assignment of benefits can’t be withheld due to non-participation with an insurance company. Why is this law important? Because there are some companies that will not send benefit checks to the dentist if they are not a contracted participating provider. This law would help move towards an environment where patients who pay for their dental insurance would be able to direct payment to the dentist who provided their care, regardless of if the dentist is an in or out of network provider.
Dental coverage helps 173 million Americans get care that is vital to ensuring good oral and overall health.
Rep. Paul Gosar’s (R-AZ) H.R. 1798, the Dental Insurance Fairness Act of 2013, will help consumers receive the full value of their dental coverage. Under H.R. 1798 all self-funded health plans that offer dental benefits will provide uniform coordination of benefits and will permit patients to assign the payment of benefits directly to their dentists.
Showing strong support by increasing the number of co-sponsors for H. R. 1798 is crucial for the bill’s overall success, as opponents are working hard at undermining the legislation, often providing misleading information about the bill’s impact.
Please write to your representative and let him/her know that supporting H.R. 1798 would ensure patients receive the full value of their insurance, as well as facilitate the delivery of high-quality oral care services for all Americans.

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