Adding A Dentist To Your Practice? Don’t Forget About PPOs

There are many operational components to consider when incorporating a new dentist into your practice. A new associate’s in-network participation with PPO insurance often gets overlooked. Be sure to keep the following in mind to better help your new associate hit the ground running.

Contracting an Associate Dentist as In-Network Provider

With some exceptions, dental insurance carriers require dental providers to complete and submit a contract or form for each location they intend to practice and participate as an in-network provider. The contracting process (to obtain in-network status) normally requires a PPO specific contract, application form, and attestation. Additionally, copies of the following documents often must be concurrently submitted: enrollee’s dental license, enrollees DEA certificate (or explanation of why no DEA and who will prescribe medication), enrollee’s malpractice insurance declaration page, enrollees employment history (by month/year, and an explanation for any gaps in work). Enrollment packets missing information can delay the contracting process.

The contracting process can often take longer than one might expect. Be sure to complete the necessary paperwork for all PPO plans you intend your associate to be an in-network provider for well in advance of their start date if possible. Your associate may not otherwise obtain their status as an in-network provider until well after they begin working at your practice.

PPO Reimbursements

It is a good practice to submit your current reimbursement fee schedule with the associate’s applicable enrollment packet to ensure the practice receives the same reimbursements for claims submitted with the associate as the treating/rendering dental provider. Also, be sure you understand how your practice is currently participating in-network (i.e. direct contracts vs. leasing arrangements and plan level participation) with each PPO plan to ensure your associate participate in the same manner (or that you have purposely deviated from how you otherwise participate).

If you are adding an associate of a different specialty type, for example, a General practice adding an Endodontist, keep in mind that some reimbursements may differ since payers often have separate reimbursement fee schedules for specialists. You may also have the opportunity to initially negotiate the specialist’s reimbursement fee schedule; an opportunity you do not want to miss.

PPO Claims

An associate employee who provides treatment is considered the treating or rendering provider while the owning doctor of the practice is the billing provider. Generally, it is acceptable to have mixed participation within a practice location and where some providers participate in-network with PPO insurance plans and other providers remain out-of-network. It is wise to confirm with each specific PPO insurance carrier whether they permit providers within the same practice location to participate in-network and out-of-network. Also, be sure to keep in mind that it is a violation of most insurance contracts to bill treatment under an in-network provider who did not actually perform the work.

Unitas Dental works with hundreds of dental practices across the country to increase PPO reimbursements, optimize PPO participation, and effectively manage PPO participation. Unitas also works with start-up practices, transition practices and offers credentialing (PPO enrollment) services.

Christi Billquist is the Director of Operations at Unitas Dental. Christi began a career working in the insurance industry while completing her Bachelor’s degree at Utah State University. Christi spent 15 years working for a major national insurance company and was awarded the honor of “Pride of the Zone,” recognizing her work ethic in Innovation and Change. In 2012, Christi decided to leave the corporate insurance world to join Unitas Dental. Over the past 5 1/2 years, Christi has become a dental insurance industry expert and has been instrumental in Unitas Dental’s growth in providing PPO negotiation, optimization, and credentialing services to hundreds of dental practices across the country. Christi genuinely loves helping dental offices increase their PPO revenue, and especially enjoys helping new business owners navigate the transition from associate to practice owner.