Evaluating In-Network PPO Participation

Dentists often enroll as in-network providers with multiple PPO insurance plans in an effort to attract new patients or to maintain current patients. Unfortunately, many dentists enroll without fully evaluating PPO insurance plans or the impact in-network participation may have on their practice. Dentists further fail to continually evaluate and manage in-network participation despite changes in their dental practice and the PPO insurance environment. Poorly planned and maintained in-network participation can make it difficult for practices to grow and maintain revenue on an annual basis.

Evaluating in-network PPO participation should include the following steps:

  • Determine the practice’s current PPO insurance revenue as a percentage of total revenue.
  • Determine each individual PPO insurance plan as a percentage of total PPO insurance revenue.
  • Determine each individual PPO insurance plan’s in-network reimbursements as a percentage of the practice’s office fees.
  • Compare and rank each PPO insurance plan according to percentage of total PPO insurance revenue.
  • Compare and rank each PPO insurance plan’s in-network reimbursement as percentage of the practice’s office fees.
  • Research PPO plan market share and/or large employer groups in the area and whom they utilize to provide/administer dental benefits.
  • Identify the PPO insurance plans that historically negotiate reimbursements.
  • Identify the PPO insurance plans that allow in-network participation through shared network relationships.

Upon completing these steps, dentists can more readily plan PPO participation and make informed PPO enrollment decisions. Decisions should be based on the following:

  • Associated discounts.
  • Reimbursement levels.
  • Impact on revenue when office fee payments are replaced by in-network insurance reimbursements.
  • Potential for new patient growth.
  • Whether the PPO plan is consistent with the practice’s overall revenue strategy.

After deciding on the specific PPO plans, dentists should further evaluate the optimal manner in which to establish in-network participation. Dentists may have multiple enrollment options including the ability to contract directly with the PPO insurance carrier, to utilize a shared network relationship or to contract with a Network company (e.g. Careington). Shared network relationships between PPO insurance carriers and participation through a Network company can often lead higher reimbursements. However, there can be both benefits and negatives to participating through these networks. Dentists should engage in thorough and careful evaluation and ensure they fully understand the associated benefits and negatives before moving forward with enrollment.

For additional information about evaluating in-network PPO participation and effectively negotiating, optimizing and managing PPO participation or to inquire about Unitas Dental’s PPO Evaluation, Practice Start, PPO Management, Patient Loyalty Builder or Credentialing services, please call 800-298-4222 or visit www.unitaspposolutions.com.

Mike Alder is the President of Unitas Dental. Unitas Dental is one of the largest PPO Management service companies in the United States representing over 1200 Dentists in over 47 states.