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Tips for PPO Fee Negotiation and Credentialing

You may think you don’t have the time to negotiate fees or get credentialed with new plans.

But the effort may be worth the increased profitability and growth of your practice.

 Amol Nirgudkar, CEO of Patient Prism, sat down with Harold Gornbein and Gavi Cohn of APEX Reimbursement, to talk about how offices can optimize PPO negotiation, credentialing, proper coding, and cash rates.

How to Optimize Dental Insurance Credentialing

Credentialing often costs practices time and money, so optimizing the process make sense.

The whole reason you get credentialed is to participate in more dental insurance programs, so make sure it’s worth it, said Gornbein.

You should look at which plans have the most members in your area. Many times, an employer near you will select a certain plan, so credentialing with the new group can put you in proximity to potentially hundreds of new patients.

“Knowing which employers participate in the plan, knowing what kind of new patient opportunity would there be for the practice. Also negotiating at point of credential. All of that contributes to increase profitability for the practice,” he said.

Opportunities to Negotiate Dental Carrier Fees

In addition to credentialing, there are other opportunities to negotiate fees.

While many dentists face capitation — flat fees HMOs pay providers to participate — Gorbein said that the emerging DHMO plans offer opportunities to negotiate if you are a specialist.

Creating opportunities for profitability doesn’t stop with fee negotiation or participating in more plans. You can find more money by coding effectively and updating your UCR, or your cash rate.

For example, you may be underutilizing certain codes that could help create opportunities for treatment care that will translate to profitability.

And when was the last time you updated your cash rate?

“If you’re not priced competitively, you could lose money,” Gorbein said.

Your bottom line may be affected in other ways too. A big trend in the industry is the emergence of DSOs, said Cohn.

DSOs — dental support organizations — have been growing 20 percent, year over year.

“These groups handle the credentialing and negotiate fee setting,” he said.

For a solo practice to be competitive, it might make sense to outsource negotiations, or at least make sure your staff’s keeping up.

Third-Party Networks

Finally, many dentists are considering third-party networks. They’re more and more popular because of the fee schedules, but there are some hidden costs.

“Although the fee schedules may be higher in many cases there are a few factors that a dentist has to concern themselves with,” said Cohn. “Number one, there is no guarantee that a sub-participating carrier will stay within that third-party relationship forever.”

Some dentists say “I have MetLife, but I heard I could get MetLife through a third-party network and the fees are higher,” explained Cohn. “You have to be very, very careful in making that decision because you’re going to have potentially a minimum of 180 days out-of-network time during that transition.”

About the Industry Leaders:

Harold Gornbein - Profile Pic

Harold Gornbein

Revenue Generation Through PPO Fee Negotiation, Coding Analysis, Credentialing and UCR Fee Analysis

Harold is Co-Founder of Apex Reimbursement Specialists, a consulting firm who works on behalf of dentists with the specific goal of increasing revenue and compliance by negotiating higher paying PPO fee schedules, coding analysis and coaching, UCR fee setting recommendation, dental credentialing, and carrier relationship management. Harold has over 25 years of experience within the insurance industry. Considered an industry insider, he's worked in sales and account management for Ameritas, Dental Benefit Providers, PacifiCare Health Systems, and United Concordia, as well as manage his own insurance agency. His wealth of industry knowledge, experience, and relationships affords Apex clients with unparalleled strategic guidance and insight. He resides in Baltimore, Maryland with his wife and five children. Harold enjoys sports, time with his family and volunteering in his community.

Gavi Cohn - Profile Pic

Gavi Cohn

Revenue Generation Through PPO Fee Negotiation, Coding Analysis, Credentialing and UCR Fee Analysis

Gavi has dedicated the last 15 years to business development at all levels; he has meaningfully applied the knowledge gleaned through his University of Maryland MBA to enhance his professional roles in both the profit and non-profit sectors. Prior to co-founding Apex, Gavi worked in sales, marketing and operations management in the insurance industry, one in which he managed his own independent agency. Gavi now focuses his marketing and management experience towards educating and servicing the needs of dental clients to maximize profit. Gavi is an educated, professional consultant whose refined skill set strengthens the negotiating power of Team Apex. Gavi is a born and bred Baltimorean who now raises his five children with his wife in Baltimore, surrounded by homegrown extended family. He enjoys music, performing as both a recording artist and wedding singer, and operates a non-profit organization for local youth.

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