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954: Big Changes With Insurances You Need to Know About – Shelley DeGroff

Working with PPOs is more confusing than ever — and it’s by design! In this episode, Kirk Behrendt brings back Shelley DeGroff, founder and CEO of PPO Advisors, to help decode the complexity around upcoming changes and help you be an active player in the game of insurance. To stay up to date with the new changes and become less insurance dependent, listen to Episode 954 of The Best Practices Show!

 

Learn More About Shelley:

Learn More About ACT Dental:

More Helpful Links for a Better Practice & a Better Life:

Main Takeaways:

  • Think of insurance as a game. Be an active player!
  • Understand the contracts you're agreeing to, long term.
  • Insurance confusion is by design. Don't just set it and forget it!
  • Audit your EOBs daily. Do the math and figure out why fees are different.
  • New associates cannot use the owning doctor's NPI-1 — it is insurance fraud.
  • Success is not determined by the number of insurance you do or don't participate in.

Quotes:

“Let's start with some of these first changes. One happened on September 1st, and that was the lease share agreement of Aetna and MetLife. That is a two-way share, meaning that you can pick Aetna up through your MetLife contract, or you can pick MetLife up through your Aetna contract. That means if you were out-of-network with Aetna, but you were in-network with MetLife, you are now considered an in-network provider for Aetna. Now, not all of Aetna's plans are being shared over. Their Medicare plans are not being shared, and their Aetna Type 1 plans are not being shared. So, those are your private-purchased plans. An individual policy that somebody goes to marketplace and purchases, that would not be shared over to MetLife. Those patients would be considered out-of-network. But any employer-based plan from Aetna would be shared over to MetLife, utilizing MetLife's fee schedule. So, now, we have, ‘Well, wait a minute. I participate with Aetna through Connection Dental or through Premier Dental. What does that mean for me?’ Well, that means the fee structure review that the networks can do internally, they'll look to see where their best reimbursement will be — the insurance company's best reimbursement — the lowest fee they can attach to. So, your Aetna through Connection may shift to MetLife if it is a lower fee schedule. If MetLife is a higher fee schedule, then it won't shift organically. You'll stay on the lower fee schedule you were on.” (3:34—5:22) -Shelley

“How is it that it is legal that [insurance companies] can make these types of changes and there's really no vast information being shared with it? That's part of the third-party contracting, the fact that these networks are able to lease out and contract elsewhere. If your contract is not held directly, they do not have to provide you the information. So, if you were a part of Aetna through Connection, you're not getting the letter because your contract is not with Aetna — your contract is with Connection for Aetna. So, you're not getting this information if you're not directly contracted. So, again, that leaves so much room for interpretation of the wrong way. There's so much misinformation out there as well, thinking certain plans will be shared when they're not, and so forth.” (5:59—6:46) -Shelley

“Another thing I want to touch on since we’re talking about Aetna and this MetLife share is that Aetna has been discussing the fact that they are removing around 90-some Medicare Advantage plans for dental. That will be rolling out over the next several months, and it's affecting about 34 states. They have not been super transparent as to which states. But again, this is something that you're going to recognize in your practice if you participate with a bunch of Medicare Advantage plans, which a lot of our practices do. They're changing that whole structure.” (6:47—7:27) -Shelley

“One of the recent changes was, you used to be able to pick up Aetna Medicare Advantage through, like, Careington. Well, that termination happened, and now the only way that you can pick this up is through either a direct contract with Aetna or through Connection. Right now, that's the only avenue for Aetna Medicare Advantage. So, it used to be through multiple shared options, but they've severed that. Now, it's just Connection or Aetna Direct. If you go Aetna Direct for your Medicare Advantage, then you are also opting to take the PPO plans through Aetna on the same fees . . . This has been very confusing. There's information out there on the web, but it's very hard to sift through. Again, we don't really know what states are being impacted. They're pretty hush-hush on that, or what plans they're eliminating altogether. So, a lot of the time, we filter those questions in front office situations where, ‘Hey, we need to renew our dental benefits. Do you accept this plan?’ well, we don't know if we will be accepting this Advantage Medicare plan or Medicare Advantage plan. They may be eliminating it. We don't know what that looks like. So, there are a lot of unknowns right now around the whole Aetna Medicare Advantage. But we do know that you cannot pick it up through any other lease except Connection, for right now, or through a direct contract.” (7:28—9:07) -Shelley

“That's a common question: I don't know what I'm credentialed with. I don't know what I'm in-network with anymore. How do you know? That web is so big, and it keeps growing, and all of these networks keep making new agreements and attaching them to other agreements. And that Most Favored Nations clause where they can come in and look to see, where is the lowest fee through your web that we can attach to that we can then drop your rates to the lowest fee schedule available because the web touches it, that's when practices start to really lose money at a fast rate without even really understanding how it happened. ‘How did it happen? We were getting paid so much better. We're contracted on this rate, but now we're not being paid that way anymore.’ It's so confusing, and it's by design. That is a by-design confusion that is definitely winning in most practices. It's just how they do it.” (10:07—11:07) -Shelley

“You really can't just take insurance in your practice and say, ‘I signed up. I did what I need to do. Now, it's out of mind. Out of sight, out of mind. We accept it, and that's all we need to do.’ That is the worst advice you could ever take, is just sign up and then forget it because you've done your part. Insurance is a game where you have to be an active player. You have to know how your contracts are set up, what they share to, and those share changes that are happening all the time so that you can reroute your fees to the best fee schedule you can obtain within your practice because the networks have the ability to change that all the time. You need to put those stopgaps in place so that they can't change to those lower fees. You can't just say, ‘I did that one change. Now, it can't go lower.’ You still always need to have your eyes on, ‘Are the EOBs paying out on the fees we think they should be paying on — the ones we set them up to be on?’ If you're not watching that continually, you are losing money in your practice.” (11:18—12:22) -Shelley

“On a daily basis, when you're putting in your payments, you should have your cheat sheet at your front desk that has the fees laminated, or right next to the PPO network. So, if I'm getting paid for an Aetna claim, then it should be paying off of Connection. Then, these are the fees that we should see on that EOB. And after a time, you're going to start to memorize those fees. You're going to see those common fees, like your prophys, your fillings. All of that is going to be second nature to you. But at some point, if you're like, ‘Well, wait a minute. That fee seems lower. Is it the deductible that changed?’ go in and do the math as to why that fee may look different. Then, you're like, ‘No, it's not the deductible,’ at the bottom of your EOB, not always, but 90-some percent of the time, there's going to be fine print at the bottom of that EOB that tells you which fee network was utilized in processing that explanation of benefits. So, this Aetna claim was processed utilizing the agreement with Connection, or with DHA, or with Guardian, or with Ameritas, or now with MetLife. There are so many options. So, if you have the ability for a web within your networking to reach all of those, it can be changing to them if you don't stop it.” (12:52—14:21) -Shelley

“The most important thing for any practice is to really understand these credentialing contracts. So, if you're bringing in an associate or you have a new tax ID, and you have this opportunity to credential, understanding what that contract you are agreeing to long term is going to determine how you can negotiate that contract moving forward. So, I'm going to use, for example, United Healthcare. They have a clause in their contract that states if you go direct with them and decide to term it and wish to get picked up through Careington, Connection, DenteMax, you will be blocked indefinitely. There is no timeline. They're going to block you from allowing you to be picked up through a different fee schedule or contract because they don't want you to be able to play the game any further than where you started. So, if you go direct, you've limited yourself to that direct contract. You no longer can get out of it and pick it up somewhere else at a higher fee. And if you are stuck in that direct contract, what gives United Healthcare any reason to increase your direct rate? You're stuck. You can't get out of it unless you go out-of-network indefinitely with United Healthcare.” (14:55—16:16) -Shelley

“You have the ability to, within your tax ID, credential, So, credentialing is done by tax ID and NPI-1. Your NPI-1 is the provider of service that follows them from practice to practice. So, you bring an associate in who has worked for another office. Their NPI-1 was credentialed with United Concordia, Connection, and some others. They have the ability to follow that associate into their new tax ID, which can wreak havoc on the entire credentialing process. In addition, though, you can credential that associate different from yourself. So, say that you, as the owner of the practice and of that tax ID, credentialed directly with United Healthcare, and now you can't get out of it. You're stuck with that direct contract. But you now have learned, ‘I don't want my associates to make the same mistake. I'm going to credential them through a different avenue.’ You can do that. Not all networks will allow that, but some will. So, again, it's back to knowing, what are the best ways to credential yourself and your associates for long-term success within your practice.” (16:49—18:01) -Shelley

“NPI fraud, especially in the case of acquisitions or bringing in an associate — acquisitions are tough because that sale, you don't really have a lot of verbal communication with the office until the sale takes place. So, it's hard to know how to even do credentialing until you own it. So, then you take over this practice. You're not credentialed, you're out-of-network, and the panic sets in, not only from the doctor but from the staff. They're like, ‘You have to be in-network. Everyone calls, and if you're not in-network, then they won't set up.’ Then they are told — which is bad advice — that you can utilize the seller's NPI and tax ID number until you're set up under your new credentials. That is identity fraud. That is insurance fraud. Then, as you get into seeing patients with Medicare or Medicaid, those rack audits are continual. So, that's something that's constantly being reviewed, and you're going to get caught on insurance fraud and identity fraud — which are federal crimes, not just the penalty of a slap on the hand, or you need to get credentialed accurately. It is a big crime. It is a big no-no. Unfortunately, we hear about it in our business all the time. ‘Hey, we were told we can do this. Oh, we have an associate. They're just going to use the owning doctor's NPI-1 until they're fully credentialed. We have to get them seeing patients.’ That is not the way to do it.” (20:54—22:23) -Shelley

“People feel like they have to be a part of insurance, especially starting out. I don't want anyone to get the misconception that PPO Advisors is only for helping practices stay in-network because that is not what we want. We are also of the mindset of what you do as well. We want to see practices lose dependency on insurance. So, if we need to keep what makes sense, then that's fine. But let's work on losing dependency on these shared contracts. The more of these contracts you have, the bigger your web is in your practice, and the more money you actually are losing because that web is so complex, and it is so hard to manage that within a dental practice anymore. We outsource so much, but you can't outsource this web. You can't have a billing company necessarily watch your web for you. It's not what they do. So, you are opening your doors to have the insurance companies dictate behind your back what you're actually going to get paid without having to send you a letter, without having to inform you that we're dropping your rates, or any of that. So, having that loss of dependency on insurance is really key to practice success, in my opinion.” (33:28—34:41) -Shelley

“Practices need to know exactly what they're getting into with insurance. It's not what it used to be in the ‘90s where you signed a contract and there were no hidden stipulations involved; it was just a contract. It is not like that anymore. There's so much more to it. So, if we can educate and help practices see where their opportunities are, and if the cons outweigh the pros, or if the pros outweigh the cons to move in those directions, then let's drop that rate of dependency. Most of the time, at least 90% of the practices that are heavy PPO we work with are overly contracted. Meaning, they have overlap of networks they don't need, and it's opening up avenues for their networks to default to lower payments, and they're losing money as a result of not knowing how to manage that. You do not need to accept every contract, and you do need to understand how those contracts can play off of each other and impact your bottom line. So, 100%, we need to lose dependency on contracts, and we need to not feel like that is the only way to be a successful dental practice.” (35:26—36:37) -Shelley

“I had a client call. We did their startup. She went in-network with quite a few, and then, gradually, we helped get out. Now, she's working three days a week. That is her goal. She's got small children. She's working three days a week. She went down from five to three, making more money than she was seeing all the insurances. Now, her fear is, ‘Gosh, if I decide to sell, I'm going to have to add insurance back in because my practice won't feel as though it's marketable to anybody else.’ I'm like, ‘You've won! You finally got to your goal. You're working less, making more, and seeing the patients that are benefiting your practice. You did it!’ And there's still that stigma out there like, ‘But I'm not involved with enough insurance to be considered successful or marketable,’ or whatever. So, really making sure these providers look at what their goals are, and what they're trying to achieve, and not what anybody else is. Realizing insurance doesn't have to play that big of a role in it — boy, that freedom is a wonderful feeling.” (38:06—39:16) -Shelley

Snippets:

0:00 Introduction.

1:53 Shelley’s background.

2:51 The current state of PPOs.

5:22 Why are these changes legal?

9:08 Confusion is by design.

11:07 Be an active player in the insurance game.

12:22 How often should you audit EOBs?

14:30 Is any of this negotiable?

16:16 Provider-specific credentialing, explained.

18:25 How long does it take to credential?

20:10 NPI fraud, explained.

23:12 Other upcoming changes.

27:57 The trend of non-dentists purchasing dental practices.

31:12 Lose your dependency on insurance.

40:45 About PPO Advisors and how to get in touch.

Shelley DeGroff Bio: 

Shelley DeGroff, founder and CEO of PPO Advisors, knows dentistry. After graduating from the University of Nebraska, she began working as a dental receptionist in a nearby dental office. After completing her certification as a dental assistant, Shelley transitioned to become a successful office manager. It was in that role that Shelley began noticing the need for PPO negotiations for her employing doctor. This experience began the business model for PPO Advisors, which has now become a nationwide industry leader. 
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