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You may think you do not have the time to get credentialed or negotiate fees with new dental insurance plans, but the effort may be worth it for the increased profitability and growth of your practice. Here are some tips to help you consider and optimize the opportunity.


There are many things to consider when deciding to go in-network with a dental insurance plan. And there are ways dental practices can optimize PPO credentialing and negotiating to increase the benefits of their network participation. The following tips apply to general dentists and specialists in private practice, group practice, or a dental service organization (DSO).


Tips for Dental Insurance Credentialing

Contracting with insurance carriers costs dental practices time and money, so make sure each insurance plan under consideration is worth the effort.

  1. Look at which plans have the most members in your area and find out which employers participate in these plans. Credentialing with a plan selected by a large employer can put you in proximity to potentially hundreds of new patients.
  2. Assess the size of the opportunity. Have other dental practices in your community already enrolled in the plan? Will enrollment help you compete? How many employees are in a target company or organization? How easily can you communicate with their HR administrator to market your services? 
  3. Understand the details of the plan itself before credentialling. Will you be able to increase profitability? Will your team be able to handle the workload of insurance claim processing?  What impact will that workload have on the entire practice?
  4. Consider how a plan might negatively affect your current revenue. If many of your existing patients have that plan, could going in-network reduce the income you now receive from them out of network?
  5. Consider how a plan might positively affect your existing patients and revenue. If many of your existing patients have that plan, could going in-network enable them to achieve more of the restorative dentistry they need?


Tips for Negotiating Reimbursement Fees

  1. In addition to credentialing, you can negotiate your reimbursement fees at the point of credentialing. For efficiency and best results, utilize a well-informed and skilled negotiator to credential and negotiate the reimbursement schedule.
  2. The reimbursement schedule for your dental services is negotiable. You can go back and forth before settling on the fees and signing a contract.
  3. While many dentists face capitation, flat-fee HMOs pay providers to participate. The emerging DHMO plans offer opportunities to negotiate if you are a specialist.
  4. DSOs handle the credentialing and fee setting for their clinicians and have the negotiating advantage of bringing many practices into the network at one time. For a solo practice to be competitive, it might make sense to outsource negotiations, or at least make sure your staff is keeping up with the latest information they need and putting serious effort into the process.
  5. Finally, many dentists are considering third-party networks. They have become more popular because of the better fee schedules. But there are some hidden costs, and 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 reimbursement fees are higher.” You need to be careful in making that decision because you may be 180 or more days out-of-network during that transition.


Other Opportunities for Profitability

Creating opportunities for profitability does not stop with fee negotiation or participating in more plans. 

  1. Many dental practices are unaware of all the insurance plans they are enrolled in. Many dental practices are underutilizing the tools provided by their insurance carrier relationships. Stop and ask yourself if your dental practice is among these?
  2. You can find more money by coding reimbursement forms effectively. Your team should include someone who is dedicated to knowing dental coding inside and out, who likes doing research, who is familiar with the reimbursement requirements of the plans, and who is motivated to optimize the reimbursement tools provided and doggedly go through the process. 
  3. You may be underutilizing certain codes that could help create opportunities for patients to afford more treatment. Have you or your team invested time and energy to research this? What income are you potentially leaving on the table?
  4. Examine the fees being charged by dentists in your zip code area and update your UCR if you have undervalued your usual, customary, and reasonable fees for patients who are out-of-network.
  5. When was the last time you updated your cash rate? Should you adjust this rate to remain competitive and be more profitable?
  6. Communicating with local employers about the plans you carry is a must-do strategy to attract the new patients you desire. Keeping a list of your in-network plans on your practice website will help attract the people you are targeting.


If you are frustrated with your insurance reimbursement or unable to effectively select plans and optimize credentialing and fee negotiation, APEX Reimbursement Specialists can help you with this. APEX Reimbursement Specialists also can help you find and correct underutilization while providing you and your team with the knowledge you need to optimally carry this forward. 

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