Creating Systems and Efficiency in Managing Insurance Participation

Dental Practices can save time and avoid frustrations by having a clear understanding of their
in-network insurance participation. It is important for office team members to know the
specific plans each dental provider participates in-network with and how each provider
participates with each plan. It is otherwise difficult to provide current and prospective patients
accurate information when discussing their insurance benefits.

In the past, insurance participation was straightforward, but has become more complex as a
result of insurance carriers leasing or sharing their network providers. For example, Principal
and Ameritas share their network providers with each other. Thus, a practice may be
contracted directly with only Principal yet participate in-network with Ameritas insured patients
through their contract with Principal. In this situation, the practice must understand treatment
provided to Ameritas insured patients will be considered in-network and reimbursements paid
according to their Principal fee schedule.

Additionally, dentists within the same practice can participate in-network with the same plans
but in a different manner. Dental providers contract individually with each insurance plan.
When a dentist contracts directly with an insurance carrier, there is a specific reimbursement
fee schedule associated with this contract.

Situations can arise where one dentist is contracted directly with a PPO plan while another
dentist in the practice is not directly contracted with this plan, but is in-network through a
shared network relationship. For example, Dr. Smith and Dr. Johnson work as associates at the
same practice. Dr. Smith is contracted directly with Principal and directly with Ameritas,
whereas Dr. Johnson is contracted directly with only Principal. Both Dr. Johnson and Dr. Smith
can provide in-network services to Ameritas insured patients; Dr. Johnson’s in-network status
via the shared network relationship noted above. Dr. Smith will be reimbursed based on her
Ameritas fee schedule and Dr. Johnson will be reimbursed based on her Principal fee schedule.

In-network participation through a third-party administrator, also referred to as a network
company, can create similar challenges. Network companies like Careington can provide in-
network access to multiple PPO insurance plans and competitive reimbursements. However, it
is important for practices to understand which plans fall under the Careington network and any
limitations. For example, Careington can provide in-network participation to MetLife insured
patients but only MetLife PDP+ plan holders (this MetLife limitation similarly applies to all
network companies). Additionally, Careington provides in-network access to Cigna insured
patients but only those patients within Cigna’s DPPO network. In-network participation through
Careington can be a good option for practices. But it is important to understand the subtleties
involved and so practices can provide accurate information to insured patients and avoid
confusion related to the applicable reimbursement amount.

Incorporating a few systems and processes into your practice can help your team understand
in-network plans and how each dental provider participates. First, prepare a map of how each
dental provider participates in-network with each plan. Be sure to note on your map the

leased/shared network relationships that exist between insurance carriers. Note specific
limitations such as “MetLife PDP+ Only” when applicable. Use your map as a guide when
contracting a new dentist at the practice and add the new dentist to your map when in-network
effective dates are confirmed. Create your map in an electronic format that can be revised and
updated as leased/shared networks change. Ensure your map is easily accessible to all team
members to reference when speaking to current and prospective patients about their insurance
plans. Finally, designate a team member to be responsible to update your map and direct
letters or notices from insurance companies to this designated person so they can update your
participation map.

Mike Alder is the President of Unitas Dental. Unitas Dental is one of the largest PPO
Management service companies in the United States representing thousands of Dentists and
Dentists in 50 states.