A New Era of Dentistry

Welcome to this week’s episode of “A New Era of Dentistry.” We’re thrilled to have “Shelley DeGroff”, founder and CEO of PPO Advisors, with us today.

Our company specializes in credentialing, negotiating, and all insurance-driven matters to help dental practices navigate the complexities of PPO solutions. We aim to secure the best possible reimbursements for dental providers through meticulous PPO negotiations and contracting. Beyond negotiation, we delve deep into educating dental practices about the nuances of their insurance contracts. This includes demystifying the fine print, revealing the strategic plays behind insurance policies, and unveiling the intricate webs woven by PPO insurance companies. Our role is multifaceted: we are advocates, educators, and strategists, all in one, aiming to empower dental practices with the knowledge to thrive in a PPO-centric landscape. Our commitment to enhancing PPO profits through informed decision-making and strategic negotiations positions us as a pivotal resource for any practice looking to improve its profitability within the PPO framework.

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Main Takeaways

1. Let’s dive right in. What exactly is an umbrella company in the context of PPOs?

An umbrella company is a third-party administrator that expands network reach for insurance providers. By using umbrella companies, networks can include more providers without direct contracts. For example, if a provider wants to join Aetna but doesn’t do so directly, they can join through an umbrella, extending Aetna’s network. Essentially, umbrella companies serve as a network of networks with one fee schedule that can be negotiated. However, it’s important to note that even if a network appears on an umbrella’s payer list, it doesn’t guarantee that a provider will be picked up through that network. Various factors, such as geographic location and the number of providers in the area, can affect eligibility. This system allows for greater flexibility and reach but also introduces complexity and uncertainty, which is why it’s crucial to understand the specific dynamics at play.

2. Are there pros and cons to using umbrella companies versus direct contracts?

Absolutely. It depends on the practice’s goals. Umbrella companies can simplify management with one fee schedule but might not offer the highest fees. Direct contracts might provide higher fees but are more complex to manage. Practices minimally involved with insurance might avoid umbrellas, while those deeply involved might benefit from them. For instance, an umbrella company might be ideal for a multi-provider practice that wants to streamline its operations and reduce administrative burden. However, direct contracting might be more advantageous for practices that prioritize maximizing their fee schedules and have the resources to manage multiple contracts. The choice between using an umbrella company and direct contracting ultimately hinges on the practice’s specific needs, goals, and capacity.

3. How do mergers, like the recent Guardian and MetLife merger, impact credentialing and fee schedules?

Mergers create automatic network shares unless opted out. For example, if you’re in-network with Guardian, you might automatically become in-network with MetLife after the merger. It’s crucial to understand these changes to manage your PPO profits effectively. When such mergers occur, dental practices must proactively review and understand the new terms and conditions. The Guardian and MetLife merger, for example, means that practices need to be aware of how their fee schedules might be affected and what new opportunities or challenges might arise. Failing to opt out of unwanted networks can lead to lower reimbursement rates and increased administrative complexity. Therefore, staying informed and taking timely action is essential to maintaining favorable terms and optimizing revenue.

4. How can practices avoid issues with shared networks and credentialing?

Regularly review EOBs (Explanation of Benefits) and stay updated on changes. Practices should understand how they’re credentialed and work with experts if necessary. Proper credentialing and regular auditing can prevent unexpected impacts on billing and reimbursements. One of the key steps is to maintain a clear and organized record of all contracts and amendments received from insurance companies. This helps in identifying any discrepancies or unexpected changes that might affect reimbursement rates. Additionally, engaging with a PPO consulting firm like ours can provide practices with the expertise needed to navigate these complexities effectively. We help practices set up robust processes for regular review and updates, ensuring they remain compliant and optimized for maximum profitability.

5. How often should dental practices negotiate their fee schedules with insurance companies?

Typically, fee schedules should be renegotiated every 24 months, although some might need it annually or every 36 months. A comprehensive PPO consulting review should be done yearly to assess the health of your PPO arrangements and identify opportunities to improve profitability. Regular evaluation helps practices stay ahead of any changes in the insurance landscape and ensures they are not missing out on potential revenue increases. During these reviews, practices should analyze their current reimbursement rates, compare them with industry benchmarks, and identify areas for improvement. Proactive negotiation can lead to significant financial benefits and ensure that practices are not leaving money on the table.

6. Can you explain what it means for a practice to be overly contracted?

Overly contracted practices have overlapping network contracts, causing more work for the front office and potential payment issues. Simplifying these contracts by reducing overlaps can streamline operations and improve PPO profits. Overlapping contracts can lead to confusion and inefficiencies, as different payers might have varying fee schedules and requirements. By evaluating and consolidating contracts, practices can reduce administrative burdens, minimize errors, and maximize reimbursement rates. This process involves a detailed analysis of existing contracts and strategic decision-making to determine which contracts to keep, renegotiate, or terminate.

7. What services do PPO Advisors offer to help with these challenges?

We offer various services, including credentialing for startups, acquisitions, and established practices. We provide a free evaluation to understand your setup and identify improvements. We aim to set up practices correctly from day one to avoid long-term frustrations and optimize PPO solutions. For established practices, we conduct a thorough review of existing contracts, identify areas for improvement, and negotiate better terms on behalf of the practice. We ensure that the credentialing process is handled efficiently and accurately for startups and acquisitions, setting the foundation for long-term success. Our services also include ongoing support and consulting to help practices navigate the ever-changing landscape of dental insurance and maximize their profitability.

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