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983: 2 Things You Must Do in 2026 to Improve Your Reimbursements – Shelley DeGroff

Insurance can be frustrating to figure out on your own. In this episode, Kirk Behrendt brings back Shelley DeGroff, founder of PPO Advisors, to decode some of the biggest changes in the PPO world and share two things you need to do to improve your reimbursements in the upcoming year. To stay up to date with PPO changes and prevent future revenue loss, listen to Episode 983 of The Best Practices Show!

Learn More About Shelley:

Learn More About ACT Dental:

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

Episode Resources:

Main Takeaways:

  • Stay on top of your EOBs by auditing them regularly.
  • Evaluate your master fee to ensure you're paid what you're owed.
  • Learn what stacking order means and how it can affect your practice.
  • Opt-outs are not automatic! Be proactive so they are processed correctly.
  • You don't need to be 100% PPO or 100% fee-for-service. Have a healthy mix.
  • Don't get complacent or comfortable. Understand the contracts you're agreeing to.

Quotes:

“[When] you do these opt-outs, they take time to process, typically 30 to 45 days. But now, it can take 90 or 120 — or they never received it, even though you've got confirmation that it was received. This is a follow-up process. This is something you have to stay on top of and really own. You can’t just, ‘I read it, I got the letter, I sent the form back, and I'm done with it.’ That doesn't exist anymore. This is an ownership of the process in order to fully see it through the way you want it to play.” (6:27—6:59) -Shelley

“I really want providers to look at how they're being reimbursed. So, take those EOBs and see how it's being processed. What fee schedule is it processing under? Does it match what you thought it should match? So, you should have a list of all of your fees in the office. I know a lot of offices may not have that, or it's not easily accessible. But ideally, you want to have all of your fee schedules in the system or in a binder, a way for you to cross-reference your EOBs to match that it's processing on the fees that it is supposed to. That is how most practices honestly are losing the most amount of money, is through processed EOBs that have shifted, that have lost their stacking order, and are now paying you less than what you agreed to have them pay you. And that's big. If you don't bring it to the insurance company's attention, they are not going to fix it out of the kindness of their heart. You have to let them know that you're not getting paid as you should. So, ultimately, we need you guys to be reviewing those details of the EOB, making sure you're getting paid how you think you should be.” (7:31—8:39) -Shelley

“I am of the belief that every time you process a payment, that you're checking that EOB or you have memorized the fees. Some of these office managers are so great, they know that Zealous pays this dollar amount, or Cigna pays this dollar amount per code. But if you haven't memorized that, read the bottom of that EOB and it will tell you, ‘This EOB was processed utilizing the agreement with X company.’ So, it's written there somewhere. Do you have to scour for it? Yes, because they're in different places on every insurance EOB. They're not all uniform, and they're not all the same. Some of them are coming through in an electronic version, and it's not as easy to find that either. So, ultimately, it does take a little bit of research if it's not jumping right out at you. That's why we want you to cross-reference it to the fee schedule that you have for that particular insurance company. But that also means you need to know how you are supposed to be getting paid. You can’t just say, ‘Oh. Well, now it's paying off of this fee schedule. That must be right.’ Was it always paying off of that fee schedule? When did it shift? Which one is higher? What's happening here? So, this is a process that has to be really scrutinized, and sorted through, and making sure that someone is on top of it and taking ownership of it.” (9:00—10:22) -Shelley

“Your master fee is your fee. It's the fee you decided that you are worthy of getting for the services you do. That's the fee that defines the service you are capable of producing for that patient. So, that's your fee. That's your value. That is not the insurance company's value. It's the value you have placed on the service you're providing. So, you should know what your inherent costs are to do that service. Meaning, what is your overhead tied into the service? How much does it cost my hygienist, my assistants, all of the supplies needed, the time in the chair? What goes into producing the service? Once you've set that fee, then that fee is correlated to the insurance companies. Then, your zip code is tied to how insurance companies look at negotiations, contracting, and all the things. So, what we really want, especially going into 2026, is for all practices to really evaluate their master fee and make sure that they're at a range that is going to allow them to be paid what they should in a range that is supported by their demographic.” (10:50—12:08) -Shelley

“The ADA states that your master fees should be set in a range between that 70th and 80th percentile. So, this confuses a lot of people. What is that? What does that mean, 70th to 80th percentile? That means that your fees are in a range where you are higher than 70% or 80% of the providers around you. So, you want to be in that 70th to 80th percentile. Which, we get this issue where providers are like, ‘Well, if I increase my fees, I'm really just increasing my write-off. So, why would I do that?’ And there are two big things here. If we continue to submit low fees and all fees are data-mined through your zip code — meaning, the insurance companies are taking that data and saying, ‘In this zip code, all providers are submitting fees around the 40th percentile. Then, why would we ever increase our fee negotiations for that region? There's no need to. Everyone is submitting right around that 40th percentile.’ So, if we keep our fees low because we don't want a higher write-off, we're not giving the insurance companies a reason to give you a higher fee. So, our master fees play a big role, universally, for the whole zip code for dentistry, in general.” (12:30—13:58) -Shelley

“You always submit your full office fee, your full master fee, on the claim to the insurance company. Then, you take the write-off. Some practices are like, ‘We don't want to see the write-off. We want to see production, so we're not going to submit our full fee because it's not truly what we're getting.’ Okay, I get that. But you can switch the reporting system to reflect both ways so that the ledgers reflect PPO fee, but the insurance companies see that your fees are $1,600, not $800. That, again, is extremely important for the demographic and for your patients. They need to see that you're writing off that much too. They need to see that dollar value and understand where you're coming from when you do increase your fees because, ultimately, you can't stay at the same fee forever. You should increase your fees every year. Your average increase should be around three to five percent, especially on your top ten codes, your most utilized codes. Ten codes generally bring in 90% of your revenue. So, make sure you're focusing, and you know what those codes are, and you're increasing those every year.” (14:19—15:29) -Shelley

“If you're seeing write-offs of $800, $900 on a crown, look at ways that you can change that. And really, there are opportunities out there. It's just not as easy to come across as it used to be. It's not as black and white — it's a game now. So, ultimately, those numbers, it's a gut punch. But then, it also should light that fire to be like, ‘We need to negotiate our rates. We need to get paid better by these insurance companies. We shouldn't be writing off this much.’” (16:51—17:20) -Shelley

“[Stacking order] is a game that insurance companies have created by design. They were hoping that providers didn't understand or didn't utilize resources to ensure that they stay at the highest fee schedule all the time. Ultimately, a lot of practices don't pay attention to that, and the insurance companies reap those benefits. So, we can't leave money behind. We can't just get complacent and comfortable and know that, ‘Oh, MetLife pays through Zealous,’ and not check that EOB and see that that stacking order has shifted, and now you are being paid significantly less for the same services you've been doing all along.” (20:03—20:40) -Shelley

“There are several contracts out there that have language in them that will bind you to it, really, for eternity. And when I say that, you're like, ‘No, there is nothing out there that will bind us to eternity. We can't forever be contracted with the network.’ But in a roundabout way, you can, because the new language states, ‘If you sign up with us directly, then you can term us but you can never get picked up through one of our shared agreements ever again. So, if you sign a contract with language like that, what incentive does the insurance company have to give you an increase in the next two years? There's nothing. There's nothing there because you can't get out of it and improve it. The only way out of it is to be out-of-network with it for the rest of your career, unless you change locations in a TIN. That would be your only avenue of ever getting a better increase or another channel of picking that contract up.” (23:48—24:48) -Shelley

“You cannot do work for free. We feel like we can, we feel like we should, and we want to honor our patients. But there comes a point when you start looking at the numbers in a business-oriented way against all of your other production, and something stands out that does not make sense. There comes a point where you can successfully drop that insurance, and you should. We really do help practices see that this isn't an all-or-nothing. You don't need to be 100% PPO. You should have a healthy mix. You should be fee-for-service, to some extent. You can move to fee-for-service, and we can help you move in that direction if that fits your goals. Everyone is at a different place in their career, so there are different options that we can explore. Going fee-for-service is tangible. That is not a unicorn option. It is a very real option, but it does take strategy. And we certainly will strategize that option as well.” (27:07—28:06) -Shelley

Snippets:

0:00 Introduction.

1:16 Shelley’s background.

2:10 A refresher on important PPO changes.

7:15 Audit your EOBs regularly.

10:23 Master fee, explained.

17:29 Stacking order, explained.

20:55 How PPO Advisors can help your practice.

26:10 Final thoughts.

28:24 More about PPO Advisors, their discount code, 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.
ACT Dental Team

ACT Dental Team

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