How To Optimize Your PPO Reimbursements
PPO participation is becoming increasingly complex, as insurance companies search for new methods to reduce reimbursements to your practice. In recent years, insurance companies have developed leasing networks that, while unknown to your practice, result in reduced reimbursements. While more states are taking action, you need professional help to get the best results.
PPO Leasing Networks Growing
While an increasing number of doctors are going out- of-network with one or more PPOs, many practices remain involved with at least one. In recent years what used to be a fairly straightforward in-and-out-of-network agreement with a single PPO has become increasingly complicated due to the growing number of leasing networks, says Kristan Palmer of e-Dental Market.
A sharing or leasing network is basically a contract between two or more insurance companies allowing them to process claims in-network through the other if a dental office does not participate directly. Recently, these arrangements have morphed into leasing that can supersede direct contracts with these companies.
For example, you may be directly contracted with MetLife for a certain fee schedule, but find that you’re actually being reimbursed at even lower fees through a network with which you participate. Insurance companies have schemed to determine the network or participation that will pay your practice the least, and that’s the reimbursement you’re going to get! This complexity is increasing, as now leasing companies are piggybacking on other leasing arrangements, so that the leasing arrangement runs several companies deep. In effect, this means your practice has more participation through leasing arrangements than what you initially agreed to, causing “PPO creep”, says Bill Rossi, an expert practice management consultant.*
However, you also have more options for remaining in-network should you terminate or opt out of a particular leasing arrangement. This underlying participation is hard to identify unless you’re familiar with how leasing works, as well as the insurance companies involved.
As a result, PPO participation has increasingly become a matter of not just negotiating with insurance companies to receive a higher reimbursement, but also optimizing your reimbursements by shopping various networks to determine where you can receive the highest fee, and severing your relationship with the others. Unfortunately, the process is complex, since there are varying details among each practice, each region, and each insurance company.
States Taking Action
These network arrangements are not only confusing to doctors, but also to patients. As a result, patients often opt-out of or postpone receiving dental care because of confusing or inadequate coverage. This has a negative, trickle-down effect on both personal and public health.
Unless otherwise regulated, insurance companies have free reign to “lease” your practice to a different insurance network, without your knowledge or consent. This not only significantly impacts insurance benefits available to your patients, but also your ability to provide accurate cost estimates for their care.
24 states now regulate the practice of network leasing in an attempt to maximize the value of dental coverage for patients. These new laws expand transparency and provide an opportunity for your practice to accept or refuse being leased, which enforces basic fairness, while reducing surprise bills for patients following a procedure.
Get Professional Help
While these new laws will prove helpful, they’re not enough. Between running both the clinical and business sides of your practice, you don’t have the time, or expertise, to sort out these complicated and ever-changing PPO networks. So, if your practice is contracted with PPO networks, you need to engage professionals to help you optimize your practice’s reimbursement.
*Bill Rossi has over 35 years of practice management experience helping private independent practices succeed. You can contact Bill at Bill@AdvancedPracticeManagement.com, 952.921.3360, or at AdvancedPracticeManagement.com. Contact Kristan Palmer, eDental Market, at eDentalMarket.com, 844.464.2777; or Becky Balok, BB Dental Consulting, at BBDentalConsulting.com, 602.908.8118 for negotiating assistance. We receive no compensation, either directly or indirectly, for recommending their services.