Fee Schedules Too Good to Be True? What Every Dental Practice Needs to Know
By Shelley DeGroff, Founder & CEO of PPO Advisors
At PPO Advisors, we work with dental practices across the country who are striving to get the best possible reimbursement rates — and for good reason. Negotiating competitive fees is vital for the health of your practice. But lately, we’ve seen an uptick in something that concerns me — dental offices being offered “too good to be true” fee schedules and accepting them without fully understanding the risks.
If you’ve recently been presented with a unicorn fee schedule — one that makes you say, “Wow, this can’t be real!” — this blog is for you. Let’s talk about why accepting a fee schedule that is too high can backfire, and how to approach negotiations the right way.
First — Yes, You SHOULD Negotiate High Fees, But Be Smart About It
Let me be very clear: At PPO Advisors, we fully support and often recommend working with umbrella companies as part of a smart strategy to maximize reimbursement. We strive to negotiate the highest possible reimbursements for every client we serve. Our goal is always to increase profitability while preserving payer relationships and network participation.
What we don’t want is for providers to be misled by fee schedules that sound amazing but aren’t realistic — because there’s nothing more frustrating than having high fees on paper that never actually get paid, or worse, result in losing network access.
So yes — seek higher fees, but do it with a solid game plan, transparency, and full understanding of what’s possible and what’s not.
What Happens When You Accept a Fee Schedule That’s Too High?
First, let’s clarify: Getting great fees is absolutely a goal — but there is such a thing as “too high” when it comes to insurance networks, especially when dealing with umbrella networks.
Here’s what many practices don’t realize:
👉 Just because an umbrella company offers you a high fee schedule doesn’t mean all their affiliated payers will honor it.
👉 When fees are set higher than what the network is comfortable paying in your area, many payers will default to using Fair Health rates or other regional limits for that zip code — and often, these are much lower than what you were expecting.
👉 Worse, payers may choose not to pick up your contract at all, effectively removing you from their network — and suddenly, you’re out-of-network with companies you’ve worked with for years.
👉 We’ve recently had an influx of clients reaching out to us, frustrated because they accepted these unicorn fee schedules through other consultants or brokers, only to find nothing is actually paying on them, and worse, they’ve lost network access they used to rely on.
Understanding Fair Health & Regional Fee Limits
You may have heard of Fair Health — it’s a database of usual and customary fees by zip code. If your contracted fees are too high, many payers will revert to Fair Health data as a justification to underpay or not honor those rates at all.
For example, if you accept an umbrella company fee schedule that promises you $ 1,500 for a crown in a market where Fair Health lists $900 as the top-end fee, don’t expect payers to happily reimburse you at $1,500. They’ll most likely default to the $900 or less, and some may even drop you as a provider because they can’t “load” that high of a fee in their system.
Direct Contracts vs. Umbrella Networks — Not All Offers Are Equal
When you negotiate directly with companies like Aetna or Cigna, those fees are more likely to be honored. Direct contracts are more predictable and stable, and when you get a great fee schedule through these channels, they show up on EOBs and are paid out as agreed.
However, umbrella networks are a different animal. They offer “access” to their negotiated rates — but that doesn’t mean every payer under their umbrella will accept those rates.
Again, we’re not discouraging umbrella networks — they are an important tool in the reimbursement game — but understanding how they function is critical to making them work for you.
The Importance of a Strategic, Transparent Negotiation Plan
Let me be clear — negotiating great fees is essential, and it can absolutely be done successfully. At PPO Advisors, we specialize in transparent and strategic negotiations, ensuring that:
✅ We negotiate aggressively — but realistically — based on your practice’s goals, region, and the network dynamics.
✅ We vet and validate offers to make sure you understand exactly what you’re getting and what to expect.
✅ We create a game plan for implementation — making sure that payers will actually pick up the fees and that you remain in-network with key players.
✅ We avoid the trap of short-term wins that lead to long-term losses, like becoming unintentionally out-of-network.
Bottom Line: If It Looks Too Good to Be True — It Probably Is (But It Doesn’t Mean You Shouldn’t Aim High)
If you’ve been handed a fee schedule that makes your eyes pop — pause before signing anything. Ask questions like:
👉 Which payers will actually honor these fees?
👉 Is there a risk that I’ll be dropped from important networks?
👉 What happens if regional limitations are used instead?
👉 Has this fee schedule been successfully implemented in my area before?
And if you’re unsure, reach out to us. At PPO Advisors, we’ve seen the pitfalls, and we know how to navigate around them. Our goal is to get you the best fees that actually work in the real world, not just numbers on paper that will never materialize.
If you’re ready to make sense of the fee schedule jungle and set your practice up for long-term success, contact PPO Advisors today. Let’s build a strategy that works — for real.