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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.”

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