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Preparing to become an out of network dentist: 3 tips

July 21st, 2022 | 10 min. read

Preparing to become an out of network dentist: 3 tips Blog Feature

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Are you considering or preparing your dental practice to go out of network with insurance? It’s definitely an important choice and becoming more popular among dentists who want to collect their full fee rather than the discounted insurance fees. 

Going out of network can be really beneficial for dental practice’s revenue. But there are a few things you need to consider and prepare for when making this decision - in order to ensure a smooth transition and financial success.

Dental ClaimSupport works with practices in-network and out of network to help increase their claims revenue. With over 10 years of service under our belts, we have seen what a smooth and no-so-smooth transition of going out of a network can look like. And when it’s not smooth - it can affect your revenue and your patients. 

So, we’re going to share 3 tips to help prepare you and your dental practice to go out network with insurance companies. 

These tips will cover why you should first review your contract with the insurance companies you’re in-network with, consider their fees versus what your future fees will be, and how to notify your patients. With these tips, you’ll face fewer speed bumps when transitioning to out of network. 

But first, let’s cover what it truly means to go out of network with dental insurance.

Being in network versus out of network with insurance companies

Being in-network with an insurance payer can be defined as being an approved provider for members of a health insurance plan. You become an approved provider through the credentialing process meaning you signed a contract to accept the terms for treating their members. 

This contract includes an agreement to charge specified fees for your services, determined by the insurance company. Your contracted fee doesn’t cover your full fee, but the tradeoff is access to the insurance payer’s members without the marketing cost.

For example, let’s say your office is in-network with MetLife. MetLife can say, “You can only charge $80 as an in-network provider for a panoramic x-ray.” But your normal fee (also called your UCR or usual, customary, and reasonable fee) is $125. 

Well, because you’re in-network with MetLife, your contract says that you agree to accept their lower fee - You would then write off $45 or about 36% of your normal fee. 

Most of the in-network plans request that you bill your full fee on the insurance claim form. You will then submit your full fee of $125, but accept $80 from the insurance plan and agree not to bill the patient the difference. You will end up writing off $45 which is 36% of your full fee because your contract fee was only $80. 

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What does going out of network look like for dentists?

Going out of network with insurance means you are not bound by a contract with your patient’s insurance plan, so you may charge your full standard practice (or UCR) fees for your services to = patients. Their plan will cover only a percentage of UCR, and you can then bill the patient for the difference. This balances the bill if the insurance allows a lower fee (called balance billing).  

If your contract with the insurance company has ended, what does this look like?

Well - A dentist who is out of network can charge the difference between their normal provider fee and the insurance plan’s allowed fee or what they deem is the usual reasonable customary fee. 

Let's be real though, if your fees are above the insurance payer’s UCR fee - you’re not going to have many patients. So typically when you go out of network, you need to do some research on what the UCR would be in your area. 

The ADA and most larger dental supply company representatives have resources to help you determine your fees. You can purchase a fee survey broken down by your zip code report from them. It is important that the report is for your zip code and not regional.  

When you purchase this report, the fees will be organized by ADA/CDT code and will have the percentiles broken down for each fee with some of the reports highlighting your fee thus showing you your percentile. Successful practices use the detailed fee survey report to balance their fees on an annual basis.

Do your homework. Many practices are surprised that their fees are below the UCR in their zip code. 

The big appeal here is that either way, your fees are not being dictated by insurance companies.

Dive deeper into the pros and cons of being in network vs out of network with insurance in our Learning Center.

Now you know the difference between being in-network vs being out of network. Let’s prepare you for this change. 

Tip #1: Consider the insurance fees versus the fees you wish to provide

With today’s inflation, we’ve seen prices of pretty much everything increase. It’s no different when it comes to your agreed-upon fees with the insurance company you’re in-network with. 

So naturally, you want to increase your fees to offset your increasing expenses due to inflation. It only makes sense! 

Well, it’s not that simple when you’re in-network. When you're in-network with a PPO, you're stuck to that fee. 

Usually, the fees you’ve agreed upon with insurance companies are updated every two years. But if a dentist doesn't think to ask for an updated fee, or they are sent one and it is ignored with the administrative staff billing the old lower fees on the claim form, it is a financial drain on the practice that must be plugged.  

We can’t stress enough why you should bill your full fee on the ledger and claim form. Build a relationship with your in-network Provider Relations Representative, be friendly and polite and you may have an easier time negotiating better allowable in-network fees. 

The point is - if you try to negotiate a new fee schedule with the insurance company and they are not the price point you need, it’s definitely time to go out of network. 

Need more claims income? Schedule a call →

What’s going to help your dental practice thrive financially?

Pay close to what percentage of your monthly income is generated by that in-network plan.  

Research how many other dental practices in the area still are in network with that plan (usually straight from the plan website you can search for dentists in a 5-10 mile radius) and if it is low, you can leverage this information to help you negotiate. 

Review your in-network fee schedule and make sure you have it dated. Most practices put the allowed amount in their practice software. For example, if Metlife sends you an updated fee allowance, you can update it in your software. When you are updating the fees in your software, you can usually edit the name of the MetLife Fee Table to MetLife Fees as of 1/1/22. 

This is an easy tip to let you know when you last received a change. Another tip is to put a reminder in your appointment book to follow up with MetLife one year later to negotiate. Pay close attention to your in-network fee schedules, because sometimes, insurance companies will update the fee schedule to lower your fees. 

This causes you to write off more and more for the treatment you provided. So compare your fee with the allowed contracted fee to determine which is best for your practice. 

Again, researching what other dentists in your area are charging is a good way to figure out if your fees are balanced appropriately, you don’t want to be too low or too high. 

This information is why it is vital to research before going out of network. If your negotiated fees are above 20% you may experience lower profits depending on how busy your schedule is.  Many practices consider the in-network write-offs as a marketing expense as they gain new patients because of the network status.  

Tip #2: Review your contract with the dental insurance company for the termination clause

It’s important to develop a successful plan to be able to go out of network.

The first thing you, as the dentist, need to do is review the contract you’ve signed. Review the documentation and what requirements you need to fulfill to leave the network. 

In almost all cases, you have to give written notice to the insurance company. Most insurance companies need notice that you wish to go out of their network between 30-90 days. Make sure you follow the contract guidelines exactly.   

What we’ve seen happen once dentists send a letter of notice to the insurance company, they'll say they never got it. Annoying, right? So then you are not out of network when you think you are. This happens more often than you’d think. 

To combat this, send your letter giving notice via certified mail. Then request a written or emailed confirmation of receipt of your letter, confirming the date you will be out of network. 

Your contract should specify where to send the letter, but this information may be outdated. Call the provider relations department and request the exact method, email, fax, or mailing address they require you send the letter to.  When it comes to dealing with insurance companies, it’s best to cover all of your bases.

Tip #3: Tell your dental patients

As dentists prepare to go out of network, we see many struggle to inform their patients. Some patients may simply decide to leave the practice, leading to a loss in revenue. The challenge with sending a letter is that they are often misunderstood, or go unread. It is best to plan as a team how you will explain it clearly and transparently to your patients. 

By providing outstanding patient service at the highest level possible, you can improve your chances that more patients will stay. If you’re getting ready to go out of network, ask yourself:

  • What is your patient reception like?  
  • Are your patients greeted kindly and addressed by name? 
  • Do you offer amenities like toothbrushes/paste/floss/ mouth rinse in the restrooms? 

Putting in extra effort to retain patients will go a long way if you decide to go out of network. It reminds them why your dental practice is so valuable. You will then feel more confident in retaining patients as you inform them of your decision to go out of network.

Create a strategy for informing your patients you are going out of network

We highly recommend that you are transparent, methodical, and prepare at least 6-9 months ahead if you can. During a patient’s visit, this is a great time to inform them face-to-face that your practice will no longer be in-network with their insurance carrier.

It might take some team planning, role-playing, and time, but this is the best way to maintain patient retention. You may also reinforce the information by sending out a letter and/or email - but if you do only a letter, it’s likely you will lose patients as some patients who don’t understand. 

Plus - some of the contracts you have with insurance companies may state that you must inform your patients. Make sure you document that your patient was informed you will be going out of their insurance network. 

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Again, it’s best to be honest and upfront with your patients when they come in for their checkups, and let them know why you are going out of network with their insurance. 

When brainstorming this strategy with your dental team, recognize what patients you need to talk with at least two to three days prior so that you will have time to gather the plan’s out of network benefit coverage. Have a knee-to-knee about your plan to go out of network. Educate patients on what out of network benefits they will have if they stay. 

Oftentimes the recare visit is still covered at 100% basic restorative 80% and major at 50% of the UCR. But, make sure you obtain and print out each patient’s out of network benefits. Show them exactly how this will change.  

Understand some patients may not have out of network benefits, or they could have lower percentages, lower maximums, and higher deductibles. Be transparent, and inform them that many patients see us out of network.    

You are going to lose a few patients simply due to money

It’s inevitable. But don’t worry - you will get new patients. Everyone has to go to the dentist! 

But when a patient does let the patient know that they can no longer use your services, let them know you are sad to see them go and they are welcome to come back anytime. 

Now it’s time to put more effort into your patient service level and marketing your dental practice. 

If you have a new patient, put more effort into their experience by doing the following:

  • Send them a welcome email or welcome letter
  • Make it easy for them to complete their paperwork securely on your website
  • Greet them warmly, get to know them
  • Give them an office tour  
  • Find out how they referred to your office and track the referral source in your software (Google, patient, sign, neighborhood etc.) 

These are just a few tips on how to draw new patients after you may or may not have lost some due to going out of network. 

Ready to make other changes to help increase your dental practice revenue?

Choosing to go out of network with insurance as a dental practice can be a great step to have more control over your income. All it takes is some strategic preparation such as reviewing your fees, your contract with insurance and letting your patients know. These tips will ensure that your transition out of network is smooth and successful.

Dental ClaimSupport has worked with all kinds of dental practices that are in and out of network with insurance companies to ensure claims are efficiently submitted and reimbursed. 

If you’re looking for other ways to ensure a smooth transition when going out of network, consider utilizing outsourced dental billing services so your team will have the much-needed time to also build relationships and schedule treatment for your patients. 

You’ll not only have a more streamlined claims process but also collect more. 

Schedule a call for a free consultation to learn more about outsourced dental billing. 

Find out how to increase income, lower costs on dental billing when you schedule a call

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