Dental Insurance Hub: Conducting annual review of PPO agreements a good practice

ADA council: Contracts affect your bottom line, so read them carefully

Editor’s note: Dental Insurance Hub is a series aimed to help dentists and their dental teams overcome dental insurance obstacles so they can focus on patient care.

It’s that time of year.

The ADA Council on Dental Benefit Programs is reminding dentists of the importance of conducting an annual review of their signed participating provider agreements.

Dentists who are considering becoming a network provider may wish to try and negotiate the terms of the insurance provider agreement prior to entering into the agreement. For dentists who are already network providers, they may also want to try to renegotiate contract terms and provisions as well, including network fee schedules.

“Understanding the details of what is often included in contracts made between dentists and third-party payers is essential because these contracts are drafted by payers,” said Kevin Dens, D.D.S., chair of the ADA Council on Dental Benefit Programs. “They may contain terms and conditions that favor the payers’ wants and needs over those of dentists.”

The ADA provides resources for handling contract negotiations with third-party payers, including negotiation basics and some practical how-to’s for dentists who want to discuss fees with payers on an individual basis.

There is also an updated online Contract Negotiation Guide for dentists to consider. The guide discusses the basic mechanics of how to negotiate non-fee related clauses prior to entering into agreements and/or when the agreements come up for renewal.

If a dentist does not have a copy of his or her signed agreement, the dentist should ask the plan for a copy, Dr. Dens said.

“Dentists need to be aware that amendments to contracts or to the provider manual or other plan policies may happen and that these amendments may be posted on payers’ websites or buried in newsletters,” he said. “As arduous as it can seem at times, be sure to pay attention to all forms of communications from payers and do not ignore anything sent by them.”

“The council is aware of amendments from payers that require exclusivity from dentists in order to get a preferred fee schedule,” Dr. Dens said. “The council has also heard about provider rating systems as established by payers, which has the potential for payers to tie fee schedules and/or payments to those rating systems in the future.”

“Thus, dentists need to keep a close eye on this as these issues are another important reason why contracts and all amendments should be reviewed on an annual basis,” said Mark Johnston, D.D.S., chair of the Council’s Dental Benefit Information Subcommittee.

ADA online resources on contracts and clauses include an on-demand webinar, Understanding PPO Contracts: What You Need to Know.

ADA members in need of advice should also consider taking advantage of the Contract Analysis Service offered by the ADA.

“The Contract Analysis Service is a fantastic member benefit,” said Jessica Stilley-Mallah, D.M.D., vice-chair of the council. “It’s important to understand the terms of the participating provider contracts you are considering so that you can decide if they’re best for you and your patients, as well as to avoid unpleasant surprises in the future.”

To use the service, submit a copy of the unsigned contract and an analysis request through your state or local society prior to signing the contract. Requests submitted directly to the ADA will be charged $50 per contract analyzed.

The ADA has an online hub for ready-to-use dental insurance information that can help dentists address and resolve even their most frustrating questions at ADA.org/dentalinsurance.