Home Forums Practice Management Systems Understanding Insurance and PPOs

7 replies, 5 voices Last updated by Melissa Dunham 2 years, 9 months ago
  • Travis Campbell

    So there always seems to be confusion for this, so hopefully this can be a reference post for a lot of you. Being in-network comes with a lot of rules and restrictions, but there are protections, rules, and loopholes that protect you as well.
    Insurance companies pull this crap because they know they can get away with it and most dentists are clueless how the “game” is played. When you don't know the rules, you will never win. They are NOT doing it for patient protection, they do it completely to lower their costs AND maintain control over the dentist. Anything the insurance company can do to lower a patient's trust in the dentist means the patients on average will get LESS treatment done and it saves the insurance company money.

    1. Non-covered benefits: there are a dozen states that specifically allow you freedom to charge any fee for non-covered services(NCS). You can find a list (see first response for link). Every state has slightly different rules on what a NCS is, so go read your specific state law.

    2. Non-use of insurance: Patients can CHOOSE to use their insurance or not. If they want you to do a cosmetic case, you CAN have them sign a waiver to refuse billing the insurance company. This is a legal binding contract that prevents insurance from getting involved in the fee process. (Ex: pt. wants veneers, the cost is too low to justify your lab and work, and they don't want to go somewhere else. They sign, you do what you want at the fee you both agree to.)
    It is no different than the patient that comes in as a cash patient, but secretly has insurance they don't tell you about. Nothing says the patient HAS to use their insurance, their choice.

    3. Upgrades. You CAN have a patient choose to have an upgrade to a procedure that is getting billed to insurance. The rules on this state you MUST give the “insurance rate only” option, and you MUST charge cash patients the same upgrade fee should you do this. None of it can be forced on everyone.
    Examples: Invisalign, gold alloy, custom staining, all porcelain margin on a PFM, metal occlusion, etc. Mostly any fee the lab charges above and beyond their normal “lab fee”. Some doctors also do this for CADCAM services; however like I stated with the rules you have to allow the patient to do the traditional option as well and you have to charge cash patients the same upgrade.

    4) Go buy Charles Blair's book: Coding with Confidence. I honestly have no idea how any PPO office runs without this book, you are literally throwing money away every day without knowing the codes and rules.

    5) Signing network contracts: WARNING!!! Insurance companies are trying to work around the state laws. Recently some have been putting language in the contract that allows them to override state laws. READ your contracts carefully. You ARE legally allowed to CROSS OUT and DATE anything in that contract you do not agree to. I also recommend the end of the contract having references to any cross outs with your signature. Most insurance companies will not bat an eye with you doing this. If one does, than you likely know they are going to be a PITA to work with and you might want to re-eval signing up with them.

    6) Federal plans. All protection goes out the window. Federal plans follow federal rules and override all state laws. The only real answer to federal plans is patients are just not allowed to get upgraded care, period. No All on 4, no cosmetics, no upgraded service.

    7) Many services are NOT just 1 code naturally. Dentures, All on 4, implants, etc. are not just 1 code. Refer back to point #4. Learn the codes.

    8) United Healthcare and United Concordia are the most difficult insurances to work with, they deny the most by far. Be warned.

    9) Build ups. Many insurance companies see the crown code as the SEAT DATE. This means naturally a build up cannot be done/filed on the same day as the crown (unless you do cadcam). This is the most common reason they like declining them. Second reason is they have specific justification for build ups, which they want documentation to prove they are needed. Photos and narrative go a long way. The best pictures to get are a) pre-decay removal, show all the crap you can, b) after build up is complete, ideally with a large color difference to see it. Doing this can cut your denial rate by 90%.

    10) Pre-Determinations: most are completely useless. Insurance companies love them because they delay care, which they track and know 70% of pre-D never become treatment filed. They also all say something like “this does not guarantee payment”….aka “I am worth less than the paper I am written on”.
    The only recommended use of a Pre-D is with treatment that has to wait anyway. Ex: You just removed and grafted a tooth. You have to wait 3-4 months anyway, get a pre-D then. Use the pre-D as a reason to contact the patient again for doing their implant (if they are not already prepaid and scheduled).

    11) Insurance Affiliations: Signing up with insurance companies is easy. WHICH ones to sign up with is where you might want help. Many of them have hidden relationships, so when you sign up with plan A, it also signs you up for plan B. Well if Plan B has a higher fee schedule, but you signed up through plan A, you actually just signed up for a lower fee schedule on BOTH.

    12) Estimates. Learning how to do these correctly can save you a ton of hassle and patient complaints. Many insurance companies will find multiple BS reasons to downgrade payment on services. Fillings and crowns are the most common. If you are new to the game, my suggestion is this:
    If the company claims 80% coverage, estimate 65%. (Covers amalgam downgrades)
    If the company claims 50% coverage, estimate 40%. (Covers crown material downgrades)
    Estimate all buildups as 0% coverage.
    Refunding money is simple. Collecting money after the fact is a PITA and what leads many offices to collections issues. Do whatever you can to make sure if your estimate is going to be off, it is going to be off in your favor. When you understand each insurance company and policy you can modify this to be more accurate, but this is a good general rule to start with.

    13) Hygiene should NOT be a loss leader. If you are not making money in hygiene, 4 things to look at:
    a) Re-eval how you diagnose perio and see if you are missing something.
    b) Add services patients pay for
    c) Cost control – Decrease time scheduled or get less expensive hygienists
    d) If none of above- get out of network.

    14) Cash = Insurance. As I mentioned above, you MUST above all else treat all cash and insurance patients the same when it comes to procedures and fees. If you charge a fee to one, you have to charge to all for the same service or upgrade.

    15) Fraud – this is a very specific term that gets misused a lot. Fraud by definition is filing for something you did NOT do, or billing higher than you would bill a cash patient for the same service. There are lots of ways you can break your insurance contract (I don't recommend), but they are not fraud; technically those are breach of contract.

    16) Out of Network. There are almost no rules when you don't sign a contract. The only two rules are #14 and #15. Almost everything else is flexible. This point alone I would argue is more important than the insurance discounted fees of reasons to get out of network, drop the rules.

    William Hiltz

    Hi Travis,

    Great summary! A couple of questions:

    #5 – can you give examples of the minefields that dentists should look for in a contract?

    #14 – When you say “cash = insurance”, do you you mean you must charge all PPO patients (for the same carrier) the same fee.



    Travis Campbell



    5) Agreements of any kind to keep negotiated fees regardless of state laws or non-covered status.  Agreements to not charge/offer upgraded service to patients.  Any agreement about specific coding being inclusive of another (BU/Crowns for ex)

    14) No.  I mean you must submit the same fee to ALL patients regardless of payment method the same fee for each service.  When you submit a fee to insurance, you are telling them THAT fee is what you charge cash patients.  To do anything else is fraud.
    Most common example is:
    “Mrs. Jones, our fee for a crown is $1200, but since you are a cash patient we are only going to charge you $1000.”   In this example your fee is really $1000, which is what should be submitted to insurance companies as your fee.  Submitting $1200 would be fraud.

    The correct way to do what this example dentist is trying to do would be:

    “Mrs. Jones, our fee for a crown is $1200, but we do offer a prepayment discount if you would like to pay $1000 now upon scheduling you can save $200.”  (The ledger should show the $1200 as the base fee)

    Paul Levine

    Very good summary. Never realized a patient could opt not to use their insurance or that you could upgrade.

    Are there groups that specialize in this that can negotiate with an insurance company for you and advise on the contract. If there are what are the normal costs associated with something like this?

    Thanks in advance



    Travis Campbell


    There are groups that will negotiate fees and help you navigate the affiliation connections between them all.  Groups like UnlockThePPO and FiveLakes.  However, to my knowledge they don't actually look at the dental contract for you, just fees.

    As far as I know, there is no specific group that will help navigate the contract itself other than a contract lawyer.  This is why it is so important to learn it yourself.  I have read dozens of contracts by now from other dentists (I have not signed a new one in 8 years).  They are boring, but not really that difficult to read or understand in most sections.

    Brian Stoute

    I am a bit unclear about Alternate benefit and downgrades.  From what I understand, the insurance company may reimburse for a lower cost procedure to the one that was actually performed. e.g reimburse for a partial denture, when a bridge was actually done.  From the above e.g. what is the patient's co pay based on? Is it the bridge that was done or the partial denture that was paid on.

    Travis Campbell


    For downgrades see point #12.

    For alternate benefits, YOU get paid based on the service you performed (bridge).  IF the insurance company has an alternate benefit clause, they will pay based on if you were doing the alternate procedure (partial).

    So let's say the negotiated rates for a bridge is $2000, and a partial $1200.  Both are major and paid at 50%.  If there is no alternate clause I would estimate insurance paying 40% ($800) and the patient owing $1200.
    If there is an alternate clause, I would estimate insurance paying on the partial 40% (480) so the patient would owe $1520.  Hopefully they will pay closer to 50%, but at least it is easy to give money back if  you are off.

    Melissa Dunham


    I agree with everything you said. with the exception of Pre-auths'/Ds. Practices really need to approach PRE-Auths/D's as a tool for the practice, and not so much for the patient. Pre-approvals can increase treatment plan acceptance, and suffice the role the a contracted practice has in disclosing non-covered benefits as deemed necessary in most contracts. The application of an comprehensive waiver to all tx plans regardless of t plan, is a strong compliment to the pre-approval/denial. All parties understand the financial outcome of treatment acceptance.

    Pre-Authorizations allow patients to make a financial decision on the treatment proposed for them. We have a 98% treatment plan acceptance rate in our practice, and my system is improving other practices. Additionally, they take the stress away from financial discussions with eager patients, whom naively believe practices know everything about their dental plans. I could go on and on about how pre-authorizations and the maintenance of their data within practice management systems can turn a dental practice AR around and keep chairs filled, but it would be a lengthy write-up.

    Dentistry is the only section of health care that does NOT do pre-authorizations for patients. With pre-auths, we help the patient tell them what they want to know and this is “How much will it cost”, and protect the office-patient financial relationship, empower treatment planning /scheduling staff with answers that they want to know as well.

    Excellent Summary you gave, and I am relieved to see it as there are a great many who simply don't understand what is going on.


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