Profitable PPO -September/October 2019

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September/October 2019

Don’t Fall for Insurance Companies’ Sneaky Tricks 3 Types of PPO Participations

Until about eight years ago, when you wanted to become a preferred provider of an insurance company, you signed up with them directly. Each company had their own reimbursement rates and schedules. This meant a lot of providers were out-of-network, which is more profitable for the dental practice and less so for the insurance company. Seeking ways to reduce payouts to the doctor, insurance companies banded together and created shared networks, which essentially means that you sign an agreement with one company but can be pulled into participation with their partner networks. As an example, a dentist can sign up with Aetna, but because Aetna has partnered with the Guardian and Assurant networks, the dentist can be pulled into those networks as a PPO provider and have to use the Aetna fee schedule for those patients! If it sounds complex, well, it absolutely is. Dozens of these shared relationships exist, with more created yearly! Then, a new layer has been created with the advent of umbrella companies like Dentemax and Zelis, which bundle anywhere from 40–200 networks under a single agreement! So, let’s look at three ways doctors currently become PPO providers.

“… THERE’S NO RIGHT OR WRONG WAY TO JOIN A NETWORK. WHAT’S MOST PROFITABLE FOR YOUR PRACTICE DEPENDS ON YOUR GEOGRAPHIC LOCATION, FEE SCHEDULES, AND OTHER FACTORS.”

TYPE II: NETWORK SHARE AGREEMENT

In this case, a doctor does not sign an agreement but becomes in- network because a company has a tie to another company. Fees can be better but are sometimes worse depending on the schedules.

TYPE III: THIRD-PARTY AGREEMENT

In the third type of agreement, you become in-network because one of the entities “bundles” you. This type can be more difficult to navigate, but it can also potentially be more profitable. A third-party agreement puts a doctor into many plans, sometimes hundreds. Regarding these three types of agreements, there’s no right or wrong way to join a network. What’s most profitable for your practice depends on your geographic location, fee schedules, and other factors. We’ll help you identify which are most profitable for you and how to make that a reality. To make our services sustainable for your practice, we’re all about empowering our clients. We’ll provide your team with coaching and training so you can feel confident about managing your PPOs once we’ve helped you optimize them.

TYPE I: DIRECT AGREEMENT

– Clint Johnson

This agreement is made directly between a provider and an insurance company. It’s usually the easiest type to deal with, but that ease often comes with the lowest fees. This agreement typically supersedes a Type II or Type III agreement.

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