PPO Dental Insurance at a Glance

Most health insurance plans in the U.S. are either managed by a healthcare maintenance organization (HMO) or a preferred provider organization (PPO). Many healthcare practitioners prefer PPO over HMO due to its suitability in terms of coverage. As you know, dental insurance works differently from other types of insurance since most, if not all, of the dental problems can be prevented and treated with less cost. In exchange for PPO insurance, however, the dentist now becomes a “preferred provider.”

Consumers still have the choice of whether or not to go to a preferred provider, but the cost will be higher in a non-preferred provider. PPOs are also simple; unlike HMOs, PPOs don't need any referrals, let alone a primary care provider, for the plan to take effect. This translates to more patients for a dentist as he can treat patients regardless of referrals. With HMOs, however, patients need proof of referral before the dentist can treat them.

In PPOs, preventive dental care coverage ranges between 80 and 100 percent, basic care at around 80 percent, and major dental work (e.g. implants, crowns) at 50 percent. For a regular check-up worth $50, the patient may only need to pay no more than $10. The rest of the cost is shouldered by the PPO. It's safe to say that patients who regularly practice proper oral hygiene get to pay less for dental care.

Renegotiating Dental Insurance Fees

Getting the perfect insurance fee schedule is certainly the ideal scenario, but it’s also rarely the case. However, what many dentists like you don't realize is that it's never too late for your office to re-evaluate its insurance contracts and renegotiate its fee schedule. Renegotiation can be beneficial—not to mention profitable—to your practice, and it's not as difficult as you might think.

Start by asking some important questions about the insurance companies your office is contracted with, such as: “When did you last negotiate the fee schedule?” It is recommended that you renegotiate for a new fee schedule annually. This will give your office a chance to receive a more substantial reimbursement for common procedures. That said, keep in mind that you can renegotiate anytime you feel your current reimbursement is inadequate.

When you renegotiate, two things will ensure a more favorable fee schedule. One is if there's not a lot of competition in your area, and the other is if you have a good relationship with the insurance company you're contracted with. In both cases, these companies will be willing to participate in the fee negotiation process.

In the end, a firm understanding of how insurance companies work and knowing what you want out of them will give you a solid foundation for renegotiation. It may seem complicated at first, but it is something that your office should do and can benefit from.