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denominator amongst overlapping partnerships. To illustrate this point, a search on the provider directory for a general dentist in Schaumburg, Illinois, for Insurance Company A returns hundreds of results. The webpage indicates that results are prioritized to show offices with greater potential cost savings. As a result, all the providers affected are revealed first. Eighteen of the first 20 contracted providers were paying from the lower fee schedule due to the network sharing relationship. The same search in Irving, Texas, yields similar but slightly better results. Ten of the first 20 providers returned in the search are being paid according to Insurance Company A’s fee schedule. How many providers nationally are being paid from a lower fee schedule instead of their actual contracted rates? Combining the searches, 70% of the contracted providers were paying off the lower fee schedule. The results show most dentists and dental groups aren’t doing anything about it. This is the problem festering in revenue cycle teams across the group practice/DSO landscape. Claims are reviewed to ensure proper payment to the way the claim was adjudicated, not to the proper fee schedule.
Complicating the matter further, there were several occasions where providers at the same facility were contracted differently. This means either the group is cross-credentialing and there was no real impact to the practice, or claims are being paid differently in the same office depending on which provider a patient sees. Surely, that is not creating the desired patient experience.
The obvious outcome of network leasing is a bigger network brought about by adding providers who have contracts with other payers. The answer is not to necessarily drop either insurance company. Instead, develop and execute a PPO participation strategy to better manage how claims are paid and do so with greater efficiency.
Case study When engaged by a group practice with nine locations, we were able to reduce PPO participation by 31%. There are many ancillary benefits to these efforts. First, we were able to protect against payers adopting the lowest common denominator approach. Secondly, we were able to keep the practice in-network and on the provider directories to extend the strategy of broad PPO participation. In fact, we were able to consolidate payers and move these four plans to higher reimbursing fee schedules which resulted in over $577,000 of annual incremental revenue. Third, we were able to meaningfully reduce credentialing workload. For each new provider, our efforts resulted in having to complete four fewer applications with four fewer fee schedules to manage at the practice level and nearly 120 fewer re-credentialing requests in a threeyear cycle. With only modest doctor turnover, shrinking participation for this group reduces credentialing costs by over $8,000 per year. Credentialing in every PPO network is no longer a viable credentialing plan. In today’s dental marketplace, the amount of overlap created as a result of network sharing requires a well-developed PPO participation strategy.
About the Author Nick Partridge is the founder and president of Five Lakes Dental Practices Solutions, a consulting and technology firm helping dental practices develop, implement and manage a PPO participation strategy to attract and retain patients. Five Lakes has helped over 2,200 practices nationwide. The company is a four-time Inc. 5000 honoree as one of the fastest growing private companies in the United States. For more than 10 years, Partridge has been an industry leader in understanding and analyzing the impact of dental insurance networks on the financial health of a dental practice. He has been featured as a guest speaker and guest columnist for many events and publications on the topic of dental insurance and dental benefits.
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Efficiency In Group Practice : ISSUE 5 • 2020
dentalgrouppractice.com
