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ATTENTION PPO Docs!

DO NOT SIGN A PPO CONTRACT UNLESS YOU'VE READ IT CAREFULLY

by Christine Taxin

A potential disadvantage for dentists who signed contracts with one Preferred Provider Organization (PPO) plan is the shock that they are now contracted with other plans. It is possible that a dentist who signs a contract with one PPO plan may have agreed to participate with dozens or even hundreds of plans across the country.  

If your contract has this information in it, make sure you have an expert looking at the risks you might be taking!  This is exactly what Links2Success does for our dentist clients…

Companies are now adding in an “affiliated carrier’s clause” that may be included in agreements you are signing. This is an agreement that makes you a participating dentist for the affiliated plan. Dental insurance and PPO leasing companies may lease their network to insurance companies with a limited or small network, or to third party administrators that do not have access to a network of dentists.  They sell you to other companies. Again, update your contract yearly and have an expert read it, since it was written by lawyers.  

By signing this agreement, you are putting your office at a disadvantage by adding other plans without knowing their names or fees. Dentists agree to charge discounted fees to gain access to these patients; patients then have access to network dentists with reduced fees.  

Plans often fail to notify dentists that they are now a participating provider with a new plan. Even though the dentist treats the patient expecting to receive the full fee, they are surprised when their office receives an explanation of benefits (EOB) statement indicating a reduced fee and restrictions against balance-billing the patient. (Make sure your office reads the EOB) 

To prevent being caught off guard, important questions to consider asking before signing an agreement with an affiliated carrier’s clause include:   

  1. What fee schedule will be in effect?  
  2. Make sure they are not using the lowest fees from a lease plan. 
  3. What processing policies will be utilized?  
  4. What types of treatments do they allow, and how often? Do they down code for services rendered, or have limitations? 
  5. How will you be notified when your name is leased to another plan?  
  6. Make sure you can approve or disapprove the addition of a plan. 
  7. Will you have the option to opt out of participation with a specific plan?   

Dentists should always carefully review EOB statements to verify that proper fees and policies are being observed per the signed participating provider agreement. In addition, dentists should check to see if their state has passed legislation regulating PPO leasing. At last count, twenty-four states have passed this type of legislation.  Be sure to contact your state dental board for updates on these laws. 

DO NOT SIGN A CONTRACT unless you’ve read it carefully and understand it fully.  Questions?  Feel free to reach out to me directly – I can help you!  ctaxin@links2success.biz  

 

 

 

Christine Taxin

Christine Taxin

Christine can’t wait to start helping dentists, office managers, and other team members learn everything they’ve been missing about navigating dental/medical insurance billing and maximizing their practice’s overall success. For more details on her exciting new credentialing program, visit the Medical Certifications section of QPro.com and find QMADC (Qualified Medical Advance Dental Coder). If you’re interested in scheduling a presentation or have any questions, don’t hesitate to contact her at ctaxin@links2success.biz, call 914-303-6464 or visit dentalmedicalbilling.com.

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