Kelsey Gorr – Director of Insurance Optimization at e-DentalMarket
Participating with PPO used to be a straightforward concept. Being in network meant simply signing direct contracts and adhering to a set fee schedule. Many providers are still unaware of PPO leasing, how it works or how to keep it from affecting the bottom line. Dental PPO leasing has pretty much leaked it’s way into every major PPO plan and the combination options to be in network are endless.
PPO leasing was designed to be a disadvantage to providers. By allowing fee schedule sharing, companies are able to pick and choose between a list of fee schedule options to process a claim and generally will use the lowest option they see available. It also allows them to have more in network providers due to contract affiliations.
I have been with e-DentalMarket for about 10 years and have seen leasing evolve over the past five years. We help dental practices of all specialties and sizes to completely optimize their reimbursements. In short, make more money for the work you are already doing. The majority of offices have their UCR fees set below the 50th percentile. Even with lower UCRs, the majority of practices that we work with have their major PPO plans paying between 40%-60% of UCR.
Aside from low paying direct contracts, leasing plays a big factor as well. Negotiating direct contracts can still be a successful process, however the only relevant leverage lies within knowing the ins and outs of your leasing options. This is where it’s easy to get lost in the maze! Even if a decent fee increase is applied to your fee schedule, that company might still have the option to default participation and pay claims on a lower paying fee schedule from one of their leasing partners. As you may see now, it’s difficult to get ahead without looking at the big picture.
Untangling this web requires a strategy & expertise. These are the steps to how we handle PPO negotiation & optimization for our many clients:
Identifying and analyzing the current structure.
Each office has a completely unique combination of how they participate with plans (direct vs. different leasing options) and what factors are affecting how those fees are paying. Our approach is never cookie cutter with blanket solutions. Identifying your unique structure allows us to customize the approach in how to negotiate with each individual carrier.
Negotiating increases to direct contracts.
This is not as simple as it sounds. Many offices attempt to do this work on their own with little success after hours and hours of headache work and follow up only to get locked into a 3%-5% increase for the next 2 years. The secret lies in the leverage and ensuring that low paying options are not keeping your carriers from increasing (they technically compete with the lowest leasing option you have.) Again, even if offered an improved fee schedule, you could have a lower paying contract that can still be used as a leasing default.
Compare & analyze current and potential options.
You can be in network with a PPO plan through 10+ different options on top of having a direct contract. In our process, this step is taking all the pieces and fitting them together into the best possible combination. Best outcome means, whatever will make you the most money!
Optimize your structure
. Leasing isn’t necessarily a bad thing! Even though it’s designed to work against you, with expertise it’s the way to get advanced results with increasing your PPO revenue. There may be contracts, companies, leasing arrangements that you are not even aware of that could be used for a handful of plans for 20%-60%+ increases.
The only way to know how to completely optimize your revenue with PPOs, is to get help from those who do this work constantly and have it down to a science. We at e-DentalMarket, have worked for thousands of providers to increase the profitability of the work they are doing. Costs of providing dentistry, continue to rise. Some PPO companies are working to decrease fees and increase leasing complexity to keep your allowed amounts on the lowest end. It is our pleasure to assist in this field and feel pride in helping dental offices and providers succeed!
Here are a few red flags that indicate that you are a great candidate to explore PPO negotiation & optimization services.
- You have thorough PPO participation with many direct contracts
- You have more than one third party administrator contract (leasing umbrella)
- You notice claims being paid inconsistently (not matching the fee schedule on file)
- You have not received increases to your fee schedules in 2+ years
- You have companies denying participation for some providers and not others
- You have confusion on what fee schedule to use for each carrier
- You are opening a new office and have yet to negotiate or contract with PPOs
Exploring solutions may be the best thing you do for your practice. These red flags mean that there are options for you to increase revenue but you may need some help getting there. My name is Kelsey Gorr and I’m the director at e-DentalMarket. As one of the first companies to start offering PPO negotiations, we have the expertise, knowledge and even more importantly, the passion to help dental professionals succeed. I have been doing this work for nearly a decade and have an extreme passion for serving the dental community through our PPO solutions.
If you have any of the red flags in your office, feel free to reach out to me for a consultation and I will be the first to tell you if our services would benefit your bottom line.