by Nicholas Partridge
To accommodate, and some would argue to capitalize, on the steady growth of employee interest in dental benefits, dental networks are working to expand the number of providers and provider locations in a network. To do, they are offering new consumer-oriented features, as well as more cost containment options for employers. These measures, along with other factors such as government legislation, competition within markets, or mergers and acquisitions, can trigger changes to the way a plan is administered, including contractual changes with providers. In most cases, carriers and networks are required to provide notifications with regard to certain changes, but it’s not uncommon to see this communication go out at the last minute, or in some cases, after some change has gone into effect. And let’s be honest, even if as a provider, you do receive these notices, how much of it do you or your staff really understand and ascertain what the implications may be?
So what does it all mean? The simple answer is that you want all of the benefits that come with joining a dental network like visibility and administrative support, but if you’re not reading the fine print, you might be in for a few unwelcomed surprises that affect the way you do business.
Your best protection is you.
The insurance industry is changing more frequently and more significantly than ever before. As a result, the only way for you to know if, when or how your participation in a network, or your contract with the network will be affected by one of many possible factors, is by making a commitment to learning and understanding how and why insurance companies partner with dental networks, and how they can legally implement contractual changes that may not even be on your radar.
Enjoy the benefits of participation, but commit to being in the know about everything participation entails and where potential problems may arise. Being knowledgeable puts you in the driver’s seat. You are your best protection against two of the most common PPO participation pitfalls.
Enjoy the benefits of participation, but commit to being in the know about everything it entails and where potential problems may arise. Being knowledge and educated puts you in the driver’s seat; it’s also your best protection against the two of the most common PPO participation pitfalls.
Possible Pitfall #1: “Who’s Your Daddy?”
As competition among carriers increases, in order to provide benefits to employer groups, dental insurance companies have worked to establish network sharing agreements thereby quickly multiplying the size and reach of their network. Over the past few years, many insurance companies have merged, acquired other entities, or established partnerships with other networks to add unique, diversified providers. Ownership of contracts may be transferred, or you may be a part of more networks than you’re aware. Following industry news is a good way to learn about these types of changes. Know your networks and what the implications of leased network agreements may mean for you as the provider.
Possible Pitfall #2: The “Language” Barrier.
As insurance company partnerships proliferate, office staff must also understand and be able to communicate whether or not the dentist is in-network. It is difficult to estimate patient payments when offices don’t have a strong understanding of which fee schedule they will be paid from which can make for an unhappy, and likely frustrated patient.
Moreover, changes in how some carriers administer dental plans can create even more confusion. It’s possible for carriers to make adjustments that allow them to pay off the lowest of the fees schedules among partners, or pay in accordance with some new partnership agreement, despite a signed contract based on a specific fee schedule. The legal grounds for this kind of maneuvering can be covered by broad language in insurance carriers’ contracts with each provider that allows them to make changes that are “in the best interest of the member”. Guess who gets to determine what’s in your patients’ best interest as it relates to their dental benefits? Yes, the carrier. Again, careful review of the contract is critical.
Like water finds the least resistant path when flowing, it’s likely an insurance companies will find the lowest fee schedule through which to reimburse a provider. Therefore, it is important for dental office management to take the following measures to avoid any surprise:
- Always verify benefits before treating a patient.
- Ask questions and keep asking until there is a firm understanding of what impact any changes to the provider’s contracting status as a result of a new partnership or other factors will have on payments.
- Be educated on the aspects of membership that have potential for contractual changes and aware of outside influences such as legislation and market competition, that may result in carriers making changes to the administration of your plan.
- Closely monitor the explanation of benefits for each claim to identify nuances and trends.
- Equip yourself with knowledge and prepare to take action if something isn’t adding up, or work with a professional consultant to help oversee your PPO participation.
Nick Partridge is the president of Five Lakes Professional Services, a Cleveland, Ohio based PPO management consultancy. For more information, visit www.FiveLakesPro.com.
