Playing the PPO Insurance Game and Winning
“Oh what a tangled web we can weave”….or something like that. This poetic statement sure does apply to all the dental offices that are trying to make sense of playing by the rules associated with PPO insurance contracts. The objective is to help you have a better understanding of how to effectively work with PPO plans that you are contracted with.
What is a PPO?
What does this mean to you? If you elect to participate with a PPO plan in order to either compete in your marketplace, acquire new patients or keep the ones that you have, because their dental coverage changed to a PPO plan, you must play by their rules or you don’t get paid. These options serve a purpose in the industry and put patients in the chair that you may not have had without the plans. But always read your contract carefully before you sign on the dotted line. It is very clear what you can and can’t charge the patients for, as well as how much you can charge the patients.
What is Covered and What is Not?
Here is an example of when the patient is responsible at 100% of your fee: You want to provide veneers for your patient for cosmetic purposes. Veneers are a “non-covered” procedure as indicated on the Fee Schedule OR they are not be listed at all. This is a procedure that is not dictated by the PPO plan regarding your fee for this service, so the patient is responsible. You would charge your “office fee” for this service.
Here is an example of when the patient is responsible at 50% of the PPO fee: The PPO covers veneers on their plan at 50% of THEIR fee and their fee is $500/tooth. You can only charge the patient $500 per tooth, and the patient is responsible for $250/tooth. If your “office fee” for a veneer is $900, you must write off the difference of $400, or you simply only charge the patient $500, depending on whether you post the PPO fee or the office fee on your patients’ ledgers.
Is $500 a reasonable fee for a veneer? You would probably say no. But if you want to provide this service for your patient AND you are participating with this PPO plan, this is what you are contracted to charge the patient. Even if the patient is willing to pay more than their 50%, you cannot, by contract, charge the patient more.
Another example occurs when the procedure is covered, yet it is denied. The PPO plan specifically indicates in the contract that it does not cover a 1-3 tooth scaling and root planing on the same day as a prophylaxis. However, your hygienist treats the patient for both procedures to save the patient time in their busy schedule. When the claim comes back, the comment on the “Explanation of Benefits” is that the scaling and root planing were denied because they were performed on the same day. Unfortunately, you must write this off. It is a covered benefit; it was just performed on the wrong day! To play the game, your hygienist should have performed the scaling and root planing on another day to comply with the contractual stipulations.
Understand the rules. When your Insurance Coordinator is confirming the eligibility of your patients, ask specific questions to help you and your hygienists understand what is covered, not covered or restricted.
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