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8.08.08 Issue #335 Forward This Newsletter To A Colleague

Nancy Caudill
Senior Consultant
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Are PPOs The Answer To Increasing Collections?

Gas is more than $4.00 a gallon, the stock market is up and down and maybe you are not seeing as many new patients as you would prefer. What can you do to keep your practice healthy?

This article addresses a few of the issues that can arise when you elect to add PPO dental insurance contracts to your practice.

Things you should know about PPOs:

  • You will never totally understand how they work or how they pay their claims.
  • Your financial coordinator will never totally understand them either.
  • Patients think they have policies that cover everything at 100%!

Obviously, these statements are exaggerated but the concept is accurate. Financial Coordinators attempt to “guesstimate” the amount a PPO plan might pay out for a claim. Filing pre-determinations for each recommended treatment phase is extremely time-consuming with no guarantee of payment and not recommended by McKenzie Management.

Unfortunately, most patients do not understand the difference between “quality” dentistry and “sub-standard” dentistry. You can relate choosing a dentist to how many of us choose tires: if they are round, rubber and the right size, they must all be the same!

Here is a simplified example of how an employer may address the rising costs of employee benefits: A Company offers a dental insurance benefit that is a non-PPO plan and pays a premium for each employee of $20/month. The Human Resources Department needs to cut overhead for employee benefits so they investigate the possibility of offering a PPO plan to their employees.

The PPO plan may have bells and whistles that would make the plan more attractive to the employees, with only one stipulation: they will need to choose a dentist on the list in order to receive the better benefit, which may be a smaller co-pay or no co-pay for selected procedures. More important, the Company saves thousands of dollars a year in dental insurance premiums for their employees and is still able to offer a dental benefit.

In this scenario, the employee/patient has an option. What will the employee/patient choose?

This is where you are affected by your patient’s choice. Should patients elect not to pay a premium for their dental plans, they choose the PPO. If you are not participating with this insurance plan, it is very likely that your patients will leave your practice to see dentists that are on the list.

Then there are the instances in which the employer has not offered an option to the employee but now the employee has a PPO plan as a dental benefit. Is this a good or bad thing? For the patient, any benefit is better than no benefit.

Now the ball is in your court because you have to decide whether to participate or not. This is not an easy decision.

Choice 1—Not Participating
A patient can elect to see a dentist that is not participating with a particular PPO. The amount of coverage to the patient is possibly reduced. In other words, instead of covering 80% of the PPO plan’s restorative fee schedule, they may only cover 50%. It may be that the fee schedule that the PPO plan uses for non-participating dentists is higher, requiring the patient to have a higher investment for the dental procedures. Any way one looks at it, patients will more than likely pay more to see you for the same procedures than they would if they chose to see another dentist that is participating with the plan.

Will you lose patients? Absolutely! Here is a quote from a dentist that was not participating with a particular PPO:

I had an attorney friend come in the other day for a second opinion and he said he hates to go to XYZ Dental but that is where his insurance is accepted.”

What are the advantages of not participating?

  • You set your own fee schedule for your procedures. Any amount that the insurance company does not cover, whether it is a PPO plan or not, is the responsibility of the patient.
  • You don’t have to “guesstimate” how much the insurance plan is going to pay.
  • You don’t have to reduce your fees for higher-fee procedures just because it is a covered expense and the insurance plan only allows for some set amount.
  • Your practice is not insurance-driven.
  • You have no need for multiple fee schedules in your computer or for writing off production for the difference between the allowable amount and your fee.
  • You may be more profitable per hour.

What are the disadvantages of not participating?

  • You will lose patients.

Choice 2—Participating
There are many PPO plans available to dentists. Do you want to participate with all of them? Probably not. It is very important to review each PPO plan’s fee schedule and compare it to your fee schedule, because this is what you are allowed to charge your patient that has this plan. You cannot ask the patient to pay the difference with most of the procedures.

Some procedures are non-covered procedures and you can ask the patient to pay (be sure to read the fine print to have a thorough understanding of what is and is not a covered procedure). It is very important that your Financial Coordinator understands this aspect of the plan.

For example, you and the patient elect to have a resin restoration placed on #31. The insurance plan only allows for an amalgam at the scheduled fee. With some plans, the patient is responsible for the difference; with other plans, they are not.

Another concern is how to handle all the various fee schedules with your software. You will need to decide if you want to illustrate the adjustment so your patients can see how you value them as a patient by accepting their insurance plan or if you want to simply post the PPO fee instead of your office fee. It is recommended by all PPO carriers that you submit YOUR fee and not the PPO fee because they need this information when it is time to review your allowable fee schedule.

What are the advantages of participating?

  • You will see an increased number of new patients because you are on the list.
  • You will improve patient retention because you won’t be losing them to a participating dentist.
  • You will be busier because patients have a benefit that allows them to accept more treatment for less investment.

What are the disadvantages of participating?

  • CAUTION! If you are not participating in a plan now but have existing patients that are on the plan that choose to stay with you, they will immediately become participants in the new plan. Results = lower payments for procedures. For example:

This change can make a difference in your collections, especially in your hygiene department. The more patients that you have with a PPO plan the larger the effect.

  • You are controlled by the fee schedule of the plan. Yes, you can attempt to negotiate with the carrier and sometimes they will increase your fee allowance, but sometimes they won’t.

There are two reasons to participate in a PPO:

  • Increase patient base
  • Retain existing patient base

These reasons equate to “busier.” Notice that I didn’t say “more money.” You can be busy and not increase your collections because of the reduced fees. Systems need to be in place in your office to effectively and efficiently manage your PPO patient base. Team members need to understand how PPOs work, as well as the importance of treatment planning and alternative financial options to assist patients in accepting necessary treatment that will not be covered under their PPO plan.

You may be seeing fewer new patients now and elect to sign up for some PPO plans that are associated with the larger employers in your area. Don’t expect to notice a huge increase in the number of new patients immediately. Unless the employer or the insurance carrier updates the “participating dentists” list, it may be next year before your name will appear. In that case, the only patients that will be affected by your new relationship with a PPO will be current patients who get a reduction of their fees! They will be ecstatic! However, at least you won’t be losing them to the dentist down the street that accepts their plan.

There is no right or wrong answer. Be informed before you make a decision and base your decisions on what needs to be done in order to stay profitable. PPOs may be your friend!

If you would like more information on how McKenzie's Practice Enrichment Programs can help you IMPLEMENT proven strategies, email

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