Dental Practices Going Out-of-Network –

the Difference Among Insurers

Shelley DeGroff, Founder of PPO Advisors

More than ever, dental practices are exploring the idea of dropping all their insurance contracts and going 100% fee-for-service. Given the relentless effort by many insurers to lower reimbursements to providers, the appeal of totally eliminating insurance-pay from your practice is not surprising.  But going entirely fee-for-service isn’t easy and making an abrupt change could seriously harm your practice.

Instead of hitting the eject button on all insurance agreements, take a gradual approach by trying to reduce your overall dependency on insurance pay. By eliminating the worst offenders, you can continue to work with insurers that are more reasonable and strike a healthier balance between insurance and fee-for-service.

Evaluate Impact of PPOs on Dental Practice

The first step is to strategically evaluate the impact each PPO has on your practice and decide whether it’s worth continuing that relationship. The evaluation will need to take into account things like patient demographics and new patient flow. Equipped with good information, you can tackle each insurance plan one at a time, starting with the carrier that has the most negative impact on your practice and working to eliminate them first.

As you conduct your evaluations, try to view any changes you make from your patients’ point of view so you can anticipate how dropping out of contract with a given carrier will affect their decision to continue as a patient.

MetLife & Aetna – Benefits Make Them Easier to Drop

One of the first questions you should ask is how dropping a PPO will impact your dental patients. Out-of-network benefits vary widely among carriers. MetLife, for example, is a major source of frustration to dental providers because of their low fee schedules, but they generally have generous out-of-network benefits. If you drop MetLife, your patients will continue to see about the same level of benefits. As a result, eliminating MetLife probably won’t cause many patients to defect. Aetna is another carrier that makes it fairly easy to go out-of-network. Patients with Aetna plans still generally get out-of-network coverage with 100% preventative, 80% basic, and 50% major.

Bottom line, if you want to get rid of insurers, MetLife and Aetna are good options because eliminating them from your practice probably won’t cause you to lose many patients. Generous out-of-network benefits are not universal, however, and Cigna is a different story.

Cigna – Better to Be In-Network or Out?

If you go out of contract with Cigna, your Cigna patients will see a dramatic drop in benefits, and you are likely to lose many of them. However, for many practices, that might not be a bad thing because of Cigna’s aggressive campaign to lower fee schedules with providers. In the past, agreements with Cigna generally required practices to write off about 20-25%, but new agreements force practices to write off around 40%, which isn’t profitable for many dental practices. If you’re seeing patients who are barely covering the costs of their treatment, you might actually be better off losing them and using your time to bring in new patients who can pay you.

What about Delta?

If you’re frustrated by your relationship with Delta Dental, you’re not alone. One of the biggest topics trending right now among providers is whether or not to drop Delta. Because of Delta’s unique position in the market, I’ve dedicated an entire blog to exploring that question.

Evaluate Insurers Annually

Striking a balance between insurance-pay and fee-for-service gives you flexibility. You have the option to eliminate insurers if they begin to negatively impact your practice, or, add a new PPO if it will benefit your practice. Keep in mind, life isn’t static, so you need to evaluate your relationship with insurers regularly. An annual evaluation allows you to stay on top of changes and will help you decide whether or not it’s worth it to stick with an individual insurer or go fully fee-for-service.

If you have questions about whether your practice is being served well by your PPO agreements or how you can become less dependent on insurance,  contact our team at PPO Advisors.  We are experts at navigating today’s complex insurance environment and strive to level the playing field for dental providers, so you can work smarter, not harder.

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