Insurance is a game, and insurance companies have the upper hand. So, what can you do to win? To help answer that question, Kirk Behrendt brings in Shelley DeGroff, founder and CEO of PPO Advisors, a company that turns PPOs into profit. She shares insight into how PPO contracts work and advice for strategically dropping your PPOs. Insurance-free is the way to be! To keep more of the money you deserve, listen to Episode 546 of The Best Practices Show!
- PPO Advisors: https://ppoadvisors.com
- PPO Advisors Facebook: facebook.com/PPOAdvisorsLLC
- Subscribe to the Best Practices Show Podcast
- Join ACT’s To The Top Study Club
- Join ACT’s Master Class
- See our Live Events Schedule here
- Get the Best Practices Magazine for Free!
- Write a Review on iTunes
Add and drop PPOs strategically.
Do an EOB audit on a regular basis.
Start credentialing as early as possible.
Negotiating isn’t easy, but everyone should do it.
Understand how to stack and navigate your contracts.
“Credentialing and insurance contracts are not what they used to be. It used to be that you could sign up with an insurance company, and you were going to get a great rate, and you were going to get patients from that contract. It doesn’t work that way anymore. You’re signing up for a contract, or with a contract, and you’re getting 50 other shared networks with that. And if you don’t set yourself up into the right contracts, you’re really backing yourself into a corner for successful PPO negotiations and contracting down the road. So, we really need to understand what we’re doing so the success of our practice can continue to grow.” (3:27—4:07)
“[Credentialing is] not fast. Nothing about credentialing is fast, so prepare yourself. If you’re a new doctor doing an acquisition or doing a startup, you need about 120 days to get yourself a network. So, don’t wait until you take ownership. Start that process as soon as you have the letter of intent signed and you know this practice will become yours, or your startup six months in advance, if you can.” (4:34—5:00)
“As you’re still building out, get your PPOs set up. You need a tax ID number, a physical address, a phone number — which, you can get a Google number and then we can transfer that somewhere else if we need to. Those are really the key things we need to get you set up with an insurance contract. So, get that process going as soon as possible. Don’t wait around and think, ‘Oh, I’ve got 30 days till closing. I know this is in the bag. Now, I’m going to start the process.’ You’re going to overwhelm your staff and you’re going to overwhelm yourself. It’s hard. It’s a long process. They don’t make it easy.” (5:01—5:37)
“Delta Premier is everybody’s worst nightmare. We’re to the point where now we’re seeing most states do not honor Premier status through an acquisition or any sort of change. So, even if you’re bringing on a business partner and you change your TIN, most states are removing the Delta Premier access at that point. So, grandfathered in is truly grandfathered in, in these states. Meaning, you can’t change a thing. So, when you buy a practice, you’ve really got to be looking at the numbers and saying, ‘Okay. When I came into this, the practice was Premier, and they were doing $300,000 in production with Delta. My reimbursements are going to be significantly less on that.’” (6:07—6:55)
“If the majority of your practice is Delta — which, almost every practice we work with, the majority of production comes in from Delta. It’s the top producer in almost every state — you’re going to see a difference of anywhere from 15% to 25% in reimbursements on Delta Premier and Delta PPO. So, those numbers need to be crunched. We definitely need to have a better game plan in place. And maybe we’re going to have to pick up a different PPO in addition to Delta PPO. Maybe we’re going to pick up Aetna now that we’ve never had. And if the rate is negotiated to 80% of the UCR of the practice, well, then that helps offset that major deficit we took by becoming a Delta PPO for the associate coming on board. And then, we can start to schedule out and not receive as many Delta patients, and we start filling our chair space with better PPOs. So, strategically looking at how we can make a better game plan, long term, with the right PPO contracts in play.” (8:34—9:34)
“Everyone should negotiate because you can still negotiate. It’s just not as easy as it used to be. It used to be a letter. It used to be, send in your UCRs, and we’ll take a look, and we’ll bump them up a little bit. It’s not like that anymore. Really, the narrative is, they try to get rid of you when you call in and ask for an increase — transfer you many times, drop your call. They hope you get busy with other things, and it doesn’t pan out. So, negotiations mean you really need to look at the big picture. Don’t waste your time in your negotiations. Understand that they’re shared contracting with every PPO you deal with.” (11:24—12:01)
“If you’re not getting the value out of the current contract you hold, look at your shared contracts and see how you can stack and navigate that whole web of agreements to your advantage.” (12:24—12:36)
“You have shared agreements, and you have umbrella companies. A shared agreement is typically, for instance, Aetna. Aetna is a direct contract. You can go to Aetna, directly get insurance from them, or an insurance contract from them, for you to be a provider. In signing that, Aetna has an agreement with Guardian, Ameritas, Principle, and so forth. It’s a shared agreement. So, now, you’re in-network with all of their shared options. An umbrella company, or a third-party administrator — TPAs are often called umbrella companies as well — that’s not typically insurance. So, when you go to Zelis, Zelis is the third-party administrator and the direct contracts shared to the umbrellas in a way to expand their network. So, when you sign up with Zelis, you’re also now getting Aetna, Ameritas, Guardian, and all those big national players, as well as a lot of small demographic players. But it’s always to expand that PPO network.” (12:46—13:49)
“You’re seeing campaigns of Cigna, Aetna, DenteMax, all these companies reducing their fees, saying, ‘Hey, you know what? We’ve paid out too much. We’ve done too much. We need to lower the pay scale for your demographic. Here’s a new fee schedule. Take it or leave it.’ That started happening in 2020 as COVID-19 came out and everybody was struggling with their businesses. Then, they dropped, ‘Hey, we’re going to reduce your fees too.’ And as one company starts doing that, they all start doing that. So, we’ve seen significant increases, a rise in these write-offs. But they’ve also still left that door open to play the game. And I keep telling my clients, ‘You’ve got to look at insurance as a game. Because that’s really what it’s turned into. Now, they’re reducing your fees here. How can we raise them somewhere else? What do we need to do to get that back to a manageable level? We really need to be seeing write-offs with the amount of overhead we’re dealing with. Our write-offs need to be in that 20% range, not 40%, not 45%.” (15:29—16:37)
“The best way to find out how you’re participating and how your claims are actually getting paid is on that EOB, because your EOB is always going to say, ‘This claim was processed utilizing the connection fee schedule, utilizing the Aetna direct fee schedule.’ The reason why that’s important is the most-favored nations clause. And every doctor should know what that is. Yet, I speak all over and nobody really knows what that is. So, the most-favored nations clause is the clause that allows the shared agreements to utilize the lowest fee schedule they can attach to within a practice. So, when Aetna shares to Ameritas, and Ameritas is shared to Principle, and Principle is shared to Guardian, they’re all connected through this web. They have the ability to say, ‘Oh, this practice, the doctor has a direct contract with Aetna. They also have one with Guardian, and they have one with connection.’ Now, they’re looking for the lowest fee schedule to process that claim on if you haven’t stacked your contracts accordingly.” (17:04—18:10)
“When you’re researching and trying to find out what’s the next step for us to do better with our insurance and you’re trying to vet that right company, negotiations is a part of it, but understanding how to stack and navigate those contracts is just as important because you can negotiate a great rate. But if it’s not placed in the right order within your contracts, it will not be utilized.” (18:13—18:35)
“Really, it’s coming down to looking at your fees, your UCR for your zip code, and then looking at all of the fee schedules available in your demographic. Fees are negotiated by zip code. So, you can’t share a fee schedule and call an insurance company and say, ‘Hey, my buddy opened up a practice. They’re in a different zip code, but I really want that fee schedule.’ You’re going to get yourself in trouble, so we can’t do that. So, it comes down to looking at the fees, looking at your master fees. And I want to put some importance on master fees. All too often, master fees are too low for your demographic. And if we continue to keep our master fees too low, then the insurance companies have no reason to increase their reimbursements. So, we have to be diligent about increasing master fees yearly. Far too often, when we evaluate practices, they’re in the 40th percentile. And they should be in the 80th.” (19:01—19:55)
“Your master fees are your UCR for the practice. It’s the UCR of the practice, and then the insurance company gives you their UCR. And then, the difference between the two, if you’re in-network, is your write-off . . . There’s a difference. And we never want to see a practice submit full fee as the PPO fee, because you are telling the insurance company, ‘Oh, we’re paying you 100%.’ ‘We’ll lower your fees next year.’” (20:09—20:41)
“I don’t want [practices] to look at the amount of contracts they hold because, ‘Oh, I only have two contracts.’ No, you don’t. Your contracts are shared out to a million other contracts. So, that is not the gauge you want to look at. It is definitely the amount of write-offs that you are providing to your patient base. So, your ratio between fee-for-service and PPO. A client that’s working with us, they can be 30% PPO and the remainder fee-for-service. We can still help. The reality is, there’s less than six percent fee-for-service practices left in the United States. Now, I think that number is going to start to increase where we are going to see, we can’t keep going. Our next step is to become insurance-free because the overhead is too high, the write-offs are too high, and the math doesn’t work.” (21:18—22:07)
“It’s so liberating to have these conversations with our clients who are like, ‘We dropped MetLife. We dropped Delta. Can you help us now with the rest of this? Can we look at the game plan long term?’ because they can’t sustain. But we don’t want our clients to feel like that’s our only option. We want to look at the numbers strategically. And our goal is to help you increase what you can, get out of what is not making sense, and then, two, three years down the road, maybe you will be completely fee-for-service. But you don’t want to jump ship all at once because that can cause a lot of stress on the whole practice.” (22:57—23:31)
“[Scheduling out is] a real gray area. It’s really touchy, and each contract is a little different. Your paid contracts, they’re a little bit more lenient on saying, ‘Hey, if you don’t want to accept new patients, that’s completely fine. If you’re not accepting new patients this month but you are next month, perfect.’ There are ways around the lingo to be able to schedule out so that you fill up chair space with the right PPO patients, and then backfill with the ones that are not paying as much. So, look at the lingo within your contract that will allow you to say the right things so that you don’t get into any legal situations. Because we are supposed to treat all patients as though they are the exact same, whether they’re fee-for-service, insurance-based — no discrimination.” (24:25—25:16)
“Communication is key here, and the understanding. Because it’s scary to go out-of-network with some of these insurances. And when you spring that on staff, they’re like, ‘Wait a minute. We’ve had families that have been coming to us for 15 years, and we’ve been accepting their insurance. You’re just going to tell them no more? They’re going to leave.’ There is a way to do this. There is a way to talk them through to where they want to stay with your practice. And if you prepare your team and they understand your end goal, the results really do work.” (26:13—26:42)
“You hear all the time that DSOs are able to negotiate better rates across the board. What’s happening is, they can leverage a fee schedule from a certain demographic and share that fee schedule across their entire group, sometimes. But it’s not that the individual provider can’t do the same thing. It’s just, demographically, they only have one region to work in. And what defines a large DSO? That changes too, with each insurance company. So, I don’t want that to get into the minds of these solo practitioners because they still have a lot of leverage that they can fight against those DSOs that are moving in.” (28:42—29:23)
“Absolutely, you can [go insurance-free]. And I would be worried if you feel like you can’t, honestly, because there are so many ways that you can grow your practice. There are in-office membership plans. There are all these other avenues that you can bring in outside revenue that’s not tied to PPOs. Now, when you acquire a practice, it’s a little bit harder because you’re acquiring a patient base that is used to those PPOs coming in. That’s where we really want to start to thin out the ones that are unnecessary and get them to a manageable level of PPOs and contracts that are sustainable. But those startups where they’re looking, if they can keep their overhead costs low and do things the right way, you absolutely can still be fee-for-service.” (30:47—31:36)
“Don’t just sit on your contracts and understanding your PPOs because it’s too overwhelming. You’re losing money if you don’t know how you’re set up. So, take charge. Start that process of figuring out our network, and don’t get so overwhelmed with the process because it can really be something that is able to make huge strides and changes within your practice by making a few easy tweaks.” (36:29—36:53)
1:59 Shelley’s background.
3:13 Why this is an important topic.
4:08 What you need to know about credentialing.
5:37 The “Premier” nightmare.
7:42 Associates need to crunch the numbers.
9:34 Add PPOs strategically.
11:07 The current landscape of negotiations.
12:36 Shared coverages and umbrella companies, defined.
13:56 Why average write-offs are climbing.
16:38 Perform regular EOB audits.
18:46 The game of insurance and looking at your fees.
19:58 Master fees, defined.
20:46 Diagnosing your involvement with PPOs.
22:07 Is fee-for-service increasing?
24:02 Is scheduling out a good idea?
25:25 Communication is key.
26:42 Will dental insurance become more like medical insurance?
28:14 Do solo practitioners get different rates than DSOs?
30:24 Can you go insurance-free in the future?
31:38 About PPO Advisors and how to get in touch with Shelley.
36:21 Last thoughts on going insurance-free.
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.