Hello, I’m Michael with Dental Advocacy Group! Today’s topic is on network sharing and payment downgrading.
When a dentist signs contracts with insurance and PPO plans, one of the least understood and oftentimes unknown aspects of the contracts, or what we call network sharing arrangements. A majority of dental insurance contracts include some type of sharing language, but it’s not always easy to find or understand, and many dentists don’t realize it even exists. Network sharing is when you sign a contract with one insurance company, and they share that contract and fee schedule with other insurances. The result is the dentist is now in network with the original insurance, but also additional insurances due to the sharing arrangements. As the dentist signs more contracts, the sharing increases resulting in overlapping contracts with the insurance companies. This gives each insurance multiple fee schedules attached to your practice, and they can use any of them to pay the claims. As you can imagine, they will always use the lowest fee schedule to pay that claim.
Here’s an example of how it works:
You’re in network with “ABC” insurance, and you see one of their patients and then follow the claim for your standard fee of $1,000. You expect to be paid the $700 right from the contract. When “ABC” receives the claim, they compare it to their contract, plus those fee schedules they have through sharing arrangements. When you receive the payment, you see that they use the “XYZ insurance fee schedule” and pay the $600 rate associated with that contract. Since you’re also contracted with “XYZ”, you are obligated to accept that payment.
This is what we call payment downgrading, and it causes several problems. First, you just got paid $100 less than you expected, so you’ve experienced a reduction in revenue. Second, how can you predict revenue when each claim can be paid using different fee schedules? Third, if you collected from the patient based on the expected $700, you may have to issue a refund or collect more from the patient. All this leads to lower revenue for your practice and administrative hassles for your team.
Dental Advocacy Group offers a fee schedule analysis that will review your fee schedules and revenue to provide specific recommendations on how to increase revenue through eliminating network sharing and payment downgrading. If you’d like to learn more, please visit our website dentaladvocacygroup.com and complete our free practice assessment. A member of our team will contact you and discuss how we can get you on the road to higher revenue and increased clarity with your insurance contracts. Thank you for your interest in Dental Advocacy Group.
I have been working with Dental Advocacy Group for just over three years now and could not be more pleased. In network providership allows for a razors edge margin for error and profitability. With that said, DAG is constantly working to negotiate fee schedules that allow maximum payment under the headings of a massive variety of PPO plans. Cornelia, Michael and their team take all the guess work out of credentialing and recredentialing that can be tedious to say the least. The fee schedules that are achieved are significantly greater than any I have been able to negotiate in the past on my own dealing with companies as a single practitioner. Whether you are in a 10 operatory, 2 doctor practice like mine, or a 3 op practice just beginning to swim in the PPO pool, constant fee negotiations are absolutely necessary. Without DAG I would not be able to achieve the results in PPO profitability that I now have. A Class A organization all around. I couldn’t be happier.
When our practice was looking for new ways to increase revenue, we hired a consultant that suggested we speak with Dental Advocacy Group regarding their program. We had tried to get fee increases from of our insurance companies and always hit a brick wall. Our fees were consistently being cut. When we met with DAG we were a little skeptical to say the least. We decided partner with DAG in hopes of seeing our revenue increase. Jaime, our account manager, has been wonderful in walking us through a somewhat complicated process. She is knowledgeable, well organized, patient and responds promptly to our questions. She kept track of our network participation status with the insurance companies while we waited for our fee schedules to switch over to the higher schedule. This process does take time, but we are already seeing significant changes in our reimbursements.