All Products

Dental insurance and PPO plans: Should you hold ’em or fold ’em?

January 25, 2021

Insurance companies seem to hold all the cards with dental practitioners. Due to the ever-changing stance at practices, the stakes have never been higher. As far as participation with insurance companies, now is probably the best time to determine whether to remain in or out of network in some of dental insurance plans. 

Consider Dr. Roy Shelburne, a practice owner, father, and grandfather found guilty of healthcare fraud, racketeering, and money laundering. As a result, he was incarcerated for 19 months.  

 Dr. Shelburne now makes it his mission to share his experience gained with other dental professionals. According to him, “A wise man learns from his mistakes. But it is a wiser man, still who learns from somebody else’s.” Today he dedicates efforts as a speaker, author, consultant, and ADA subject matter expert.  

In this article, Dr. Shelburne will share guidance on dealing with dental insurance and PPOs today and determining whether dentists should still be in-network or move out of a network. 

In or out of network? 

Remaining in-network may provide several benefits, but a very keen sense of participation is essential. The only way to properly determine its impact on dentists and their practices is through tracking.  

Dr. Shelburne explains what to take into account to evaluate the contribution of dental insurance plans to practice: 

 1. Write-offs 

For those who are in-network, charges should always be on the claim form to track the write-offs. Insurance companies may provide substantial fees, but it is not the only aspect an insurance plan requires. Regrettably, dentists barely read the fine print to learn the obligations. Other restrictions and limitations on the program extend beyond the write-offs. These guidelines may limit reimbursement and the collection of payments from patients.  

 2. Fees 
Putting the full fee on write-offs can make tracking more convenient due to the following: 

  • Insurance companies use the fees submitted on the claim form to calculate their UCR (Usual, Customary, and Reasonable) amount.  If dentists only list the insurance company’s price, it will look like the insurer is paying 100 percent of the dentists’ fee. 
  • If a patient has multiple insurance plans, their provider will coordinate and pay more than the lowest fee schedule. The patient will receive the benefit of the lowest fee schedule.  

 For example, a patient receives a crown procedure and uses primary and secondary insurances. The primary insurance has a limitation of $900, while the second has $700. The patient will get the perk of $700, and that’s the maximum amount they can get for the crown procedure. However, if the combined insurance payment is $950, dentists need to write-off the $50 down from the $1,000 crown fee.

  • If the full fee is not indicated on the claim when writing-off after the final payment, it is difficult to identify how much was written-off on the plan. Hence, it’s crucial to put the exact data used for full fees.  


3. Insurance aging 

Be sure to track insurance aging: 30, 60, and 90 days. Always take note of claims not submitted, and run that report daily. All requests must be released on time.  


4. Rejected claims 

Track rejected claims to review why they were denied to ensure they won’t occur again. Common causes of rejected claims are use of an incorrect code, or a repeated error. Distinguishing and resolving the mistake may significantly reduce the resources spent on re-submitting claims. 


When re-submitting a claim, have the following available 

  • The credit balances to the dentists’ claims. The balance amount must be correct and not contradictory to the write-offs. 
  • The Explanation of Benefits (EOB) from the primary claim. The EOB applies to secondary claims that weren’t initially submitted.  


With COVID-19 protocols leading fewer patients to visit dental offices, dentists must identify which plan is most favorable to their current situation. Tracking and reviewing the items mentioned above will help create a resolution. 


How to communicate with patients about being in or out of network 

“Communication skills are vital,” said Dr. Shelburne. Every person in practice needs to address these questions from patients: 

  • “Do you take my dental insurance?” 
  • “Why are you dropping my insurance?” 

 Communicate the information clearly and accurately so that dentist and patient are on one page. If not addressed well with patients, the outcome might beYou’re not taking my insurance anymore, so I must switch dentists.” 

What’s essential? Knowing how to discuss the topic with patients 


Five statements to avoid telling patients about insurance  

 According to Dr. Shelburne, the following statements must be avoided: 


  1. “Your insurance will . . .” 

Never suggest that the insurance will or will not do something. Even with a pre-estimate indicating it would cover a particular dental procedure, a disclaimer exists that there is no payment guarantee. 


  1. “We are going to send a pre-determination or pre-d.” 

Never send pre-d unless the insurance company asks for it. Also, remember that sending in a pre-d will only delay the process and allow a patient time to decide against the procedure. 


  1. “We will accept the insurance payment as payment in full.” 

Saying this to a dental patient is against the law. The American Dental Association (ADA) considers any attempt to collect copayments and deductibles as overbilling.   


2. “We will bill your insurance and send you a statement after we receive the insurance reimbursement.” 

Never wait until the Explanation of Benefits arrives to bill a patient. Be very diligent about having the correct information on your database. Make an accurate estimate and collect the patient portion before service or at time of service. Otherwise, plan to spend a lot of time pursuing payments.  


3. “No, we do not take your insurance (unless you do not file or accept assignment of benefits).” 

Instead of saying “no,” lead patients into a conversation where it’s possible to help them understand why the practice does not accept their insurance.  


Talking points to consider 

  •  “Do I take your insurance? I’d love to be able to answer that question. But before we do that, could we have just a short conversation about what you need and whether you would potentially be a good fit in our practice? We may not be the right one for you.”  
  • “To be honest with you, we are not in-network. However, we accept the assignment of benefits. The only amount you are only going to need to pay is what insurance will not cover. The doctor has decided to be out of network because your plan has limitations. He/she cannot provide you the level of care that we think you need and would benefit from. However, we will file the claim for you. Again, we’d like to emphasize that the only amount that you’re going to need to pay is the amount that the insurance does not cover.”  

 Communicating changes to your patients, including dental insurance, will help gain understanding and trust. Let them know and feel that a proper evaluation was made before arriving at that decision.  

Most patients find it difficult to understand their benefits. Having many different plans and contracts can be confusing for them. Besides talking with them, providing patients with a written guideline would ensure that all on one page. 

 What is the future of dental insurance? 

As explained by Dr. Shelburne, more and more limitations will arise in dental insurance plans. Employers are searching for ways to minimize the charges and the expenses they incur. He also mentioned that PPO plans will continue to thrive because employers and patients want to have the most cost-effective products and services. The only way to promote cost-efficiency is by cutting benefits and establishing limitations. Nevertheless, some practices can make it work.  


In contrast, practices that want to provide a very high level of care may find it impossible to exist in a PPO environment. It’s not possible to run a high-touch, boutique type of practice and be a PPO practice at the same time. A PPO patient will generally select doctors in PPO. 


Succeeding in today’s dental world 

With the limitations in the industry today in mind, Dr. Shelburne suggests four ways that dental professionals can thrive in their practice.  


  1. Openly communicate expectations to the teams and patients. 
  2. Invest in systems that provide a clear understanding of the impact of being in and out of network. 
  3. Train and educate staff and patients on all guidelines and provisions of the network.  
  4. Learn to delegate, train, trust, and verify. 


Whether a practice should be in-network or out of network is a decision that must be madby every dentist. Nevertheless, as Dr. Shelburne advised: 

  • Move out of the least beneficial network for the practice; 
  • Know the write-off percentage;   
  • Determine the number of patients that under that plan; and  
  • Enhance communication skills with patients.  

 With all things considered, dealing with dental insurance and PPO plans means understanding the rules and playing by them. Let this guideline from Dr. Shelburne on insurance participation helps decide whether to hold ‘em or fold ‘em. 




3 Facts You Might Not Know About Your Dental Insurance
Insurance & Billing

As dental professionals, to be in-network is not about benefiting from dental insurance alone. It is crucial to know its types and, most importantly, to review [...]

Exploring Medical Coding and Billing: 5 Ways to Get Paid Correctly
Insurance & Billing

Medical coding and billing are two different processes. Both are essential for healthcare providers to obtain reimbursement.  Medical coding involves the r[...]

Building Your Future in Dentistry: Beyond PPOs
Insurance & Billing

For many young dentists, being a part of a Preferred Provider Organization, or PPO, may seem like the best option to broaden possibilities when cultivating a de[...]

Five steps to help establish an in-office Private Dental Plan (PDP)
Insurance & Billing

Tired of tussles with insurance companies and the aggrieved patients they often produce? Consider a self-administered in-office plan instead. Have you ever c[...]