Profits and the PPO Insurance Network

Making a profit doesn’t come easy when you are trying to provide the best state-of-the-art technology while being held by the limits of the PPO discounted network fees.  When PPO network fees are not updated yearly but costs to dentist go up it makes it especially hard to be in the black at the end of the month.

Out of network doesn’t mean the opportunity exists to make more money when the demographics dictate that there are a few major employers providing a larger number of potential patients who are looking for “in network” providers.

Let’s face it, unless the dental practice can prove otherwise, the patient is looking to save money and to them a filling is a filling no matter who puts it in the tooth.

An out-of-network provider may lower his/her standard fee to the allowable or discounted fee offered by the insurance company group plan but must still collect applicable co-insurance and deductibles.  If the dentist does not bill the insurance company for more than the allowable or UCR fee established by the insurance company.  This keeps the providers that are out-of-network from submitting inflated fees to achieve a higher reimbursement from the insurance company but not intending for the patient to pay that amount.

According to the ADA, every dentist should submit their standard or regular fee schedule on all claims going out.  The standard or regular fee schedule should be evaluated yearly for possible raising if materials, supplies and salaries continue to rise.  The standard fee schedule should be about the 80th to 85th percentile especially if any discounts are being applied to services other than the dental plan adjustments.   The insurance company bases its UCR fee schedules on the claims submitted and the fees filed on those claims.   Though an out-of-network dentist may charge whatever he or she wants, it can throw up a red flag if the charges are varying greatly for the same services from one patient to another.