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Are PPOs Worth the Hassle? – Episode 221


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Is there any way to take the frustration out of dealing with PPOs?

On this episode of the Dentist Money™ Show, Ryan interviews Matt Hironaka of Unitas PPO Solutions. Do you need help evaluating your PPO participation? Are you involved with PPOs and want to improve reimbursements? Or are you wondering if you can negotiate higher fee rates? 

Matt answers those questions and many more as he and Ryan discuss PPOs in depth. Frustrated with your PPO relationships (like so many dentists)? Matt has some reliable tips to help you smooth out those disappointing PPO bumps.


Podcast Transcript

Ryan Isaac:
Hey Dentist Money Show listeners. Thanks for joining us on another episode of the show today. I have my guest [Matt Hirinaca 00:00:08]. Matt is with Unitas PPO solutions. They are the company you would call when you’re starting to wonder if you should accept a new insurance plan, renegotiate your fees, work on contracts, anything that has to do with insurance. We got through a lot of great content today, a lot of good questions about things to look out for if you’re a startup, things to consider if you’re an experienced practice already established with insurance plans. And we got into some pretty specific listener questions with this as well. So my thanks to Matt, this is just full of content. And my thanks everyone for joining us. We really appreciate the support. Thanks for tuning in. If you want to ever have a chat with us, just please go to dentistadvisers.com click on the book free consultation link and we’ll talk to you soon. Thanks for joining us.

Announcer:
Consult your advisor or conduct your own due diligence when making financial decisions. General principles discussed during this program do not constitute personal advice. This program is furnished by Dentist Advisors, a registered investment advisor. This is Dentist Money. Now here’s your host, Ryan Isaac,

Ryan Isaac:
And welcome to the Dentist Money show where we help dentists make smart financial decisions. I’m your host Ryan Isaac, joined today by a friend of the show and someone we’ve known for a long time. Matt Hirinaca of Unitas Dental. Matt, thanks for joining us. How are you doing today man?

Matt Hironaka:
I am good. I appreciate the opportunity to be on your show today.

Ryan Isaac:
Yep. So thanks for taking the time, man. You are in the outside of Phoenix, Arizona area in Mesa. Is that right? That’s where Unitas is located?

Matt Hironaka:
That’s right.

Ryan Isaac:
All right, so let’s give a quick intro to anyone who doesn’t know what Unitas Dental is. So I always think it’s kind of funny when like I have an intro that I read to you, and you’re the expert on the thing I’m reading anyway. So the short version is, and then I’d actually like to just have you kind of introduce Unitas and what you guys do, but you guys work with hundreds of dental practices all over the United States. You’ve been doing it for how long now? It’s been a while.

Matt Hironaka:
Close to 10 years now.

Ryan Isaac:
Long time. And your whole goal is to help people manage your in network PPO participation, reimbursements, fee schedules. Knowing which ones are the right ones, how to charge, what not to take. But let me just give it to you to introduce Unitas in a way that you would want everyone to just know who you are and what you guys do.

Matt Hironaka:
Yeah, I think you summed it up well. I mean we, we’ve been working with dental practices for a number of years. And really our goal is to help them understand how they’re participating in network with PPO insurance plans. What their reimbursements are, how they can maximize them, what things that they can do from the standpoint of evaluating how they participate with each plan, the reimbursements they receive, what opportunities there may be to increase the reimbursements. And obviously that impacts practices financially in a pretty significant way. For most practices the majority of the revenue is being controlled by third parties. So we think it’s really important to manage carefully how they participate in the reimbursements that they receive.

Ryan Isaac:
Yeah, that’s really helpful. So in a nutshell, if someone is listening and they’ve been wondering, am I taking the right insurance plans? Am I charging enough for certain procedures? Have I negotiated the proper rates with my insurance plan? Should I drop any? These are all questions that you guys are experts in your field. That’s your business.

Matt Hironaka:
Yeah. We certainly try to help them make those decisions, make informed decisions. I think that’s a big key, is that a lot of times they don’t have access to the same information because we work with so many doctors across the country, that we have. And we’re talking to the representatives from insurance companies. We want to make sure that they have the right information in order to make good informed decisions.

Ryan Isaac:
Yeah, that’s awesome man. I like that. I mean we’re big fans of making decisions, especially big financial decisions with the help of context and data. So before we jump into anything else, how about a little background on how did you get involved with this? Where did Unitas begin? What led you to this point where you’re at now?

Matt Hironaka:
Sure. Well Unitas was founded by our company president Mike Alder. He had actually owned a medical device company for about 25 years. He was a University of Utah graduate, played football there. Actually thought about going into dentistry, but kind of got a job with this company, and then later bought it. And so around the time that he sold his business, his youngest son who graduated from dental school. Like a lot of fathers do, they took an interest in what their children were doing, and wanted to help him set up to be successful. And in looking at the contracts and how to participate with insurance, realized, wow, this is really impactful for practices. And I bet there’s a lot of other dentists and dental practices that could just use help, could use assistance in this area.

Matt Hironaka:
And so that’s really where we started. And especially over the last five years, we’ve grown pretty significantly as far as a number of locations and in dentists that we work with. And have tried to define different service offerings that meet the needs of the customers that we’ve spoken to. The many dentists that we’ve had conversations with and identified different types and different needs that they have. And so we’ve tried to put together different service programs that meet the needs of established practices, that are already contracted and participating in network with multiple plans. And how to manage and evaluate that participation in those reimbursements for doctors that are just buying a new practice, or building a new one. And so we need help figuring out what plans to join and where there’s the ability to initially negotiate reimbursements.

Matt Hironaka:
And then also a lot of primarily fee for service practices that haven’t contracted as an in network provider with PPO plans, but feel like they may need to at least start to consider that at this point. So we’ve tried to develop these programs. A good way of providing a service that makes sense, that allows us to do a good job. And we’ve also have some other services that are going to stand alone as far as credentialing, contracting the doctors practices don’t want to fill that paperwork out. Or don’t know where to get the information from.

Ryan Isaac:
It’s a long process, isn’t it?

Matt Hironaka:
It can be. Yeah. It certainly can be. Depending upon the state and the insurance company. I mean we’ve seen some states with some insurance companies taking four months from the date they receive the paperwork. So…

Ryan Isaac:
Well thanks for that background and intro. So a little bit different format today. I’ve got four or five bullet points that we’ll cover that I think a lot of people ask. These are questions that are pretty prominent that you can answer. But so what I’m going to do though. I was telling you this earlier, this morning actually got a really great detailed email from a client about this subject, about his own practice, and his insurance, and in house payment plans, and fees, and should I take this insurance company, or drop it.

Ryan Isaac:
So I’m actually going to list the questions so our listeners know what we’re going to cover today. And then I’m going to kind of just give you the context of this email and we can just totally free form. Like you can directly answer some of this question or you can get to some of these points that I’ll list out, kind of in context of the question. But I think it’ll really bring this thing home to a really specific point. But some of the things we’re going to cover today.

Ryan Isaac:
Some of the questions are what are some of the things that frustrate dentists about PPOs? So we’ll talk about that. What should dentists keep in mind when evaluating PPO participation and attempting to negotiate reimbursements? How does Unitas help its customers manage PPO participation and reimbursements? PPO participation, I’m going to say that like 10 times today and that’s… I’m not realizing that’s a mouthful.

Ryan Isaac:
Hey Matt, what do you like to drink or snack on when we do our webinars every month?

Matt Mulcock:
Yeah, it’s a good question. I’m usually hitting a Red Bull, but it’s hard because it’s an evening webinar.

Ryan Isaac:
These evening webinars taking place, 6:30 PM Mountain Standard Time.

Matt Mulcock:
Mountain Time.

Ryan Isaac:
Once a month.

Matt Mulcock:
Where do you find it?

Ryan Isaac:
Well if you’d like to find the webinar or you’d like to register for it, you go to dentistadvisors.com/webinar or just go to the website and click on webinars under the education tab.

Matt Mulcock:
It’s a good time.

Ryan Isaac:
It’s a great time. What kind of things do we cover in our webinar Matt?

Matt Mulcock:
So each month we’re going to hit an element, right? So it’s going to be some component of your financial life. We’re going to dive a little bit deeper than we would like on the Dentist Money show, right? We get to draw pictures. There’s live polls. You can ask questions.

Ryan Isaac:
Yeah, it’s a great time.

Matt Mulcock:
Yeah, it’s a good time.

Ryan Isaac:
Well, we’d love to see you in attendance at one of our fantastic webinars. Just go to dentistadvisors.com sign up today for the next one. Thank you very much.

Ryan Isaac:
Let me get to the email. I’ll keep any identifying information out of here as much as possible. So this person, it was just this morning, it was like so perfect and I actually responded and said, “Hey, I’ve got a great interview on the show today. I will get back to you with some good content and questions and then you can get in touch.”

Matt Hironaka:
Oh, that’s great. That’s great timing.

Ryan Isaac:
Okay, so here’s a few points he says, and by the way, this is a specialist practice, think it’s okay to say it’s a pedo practice. A couple producers, it’s been in business for quite a while, great reputation, high producing office. It’s been a pretty established place. He says a couple of things here. “We’re past due on updating our fee schedule, and I think it’s time to look at whether our strategy for private insurance is good or not.”

Ryan Isaac:
That’s one thing he says. He says, “We’re only taking currently two insurances, one of them being Medicaid.” And that’s like half of the patient base. So this is a pretty common pedo situation in a lot of places. “The other main provider has not been willing to negotiate or work with their contracted rate for the last decade.”

Matt Hironaka:
Okay. I can imagine who that might be.

Ryan Isaac:
Yeah. So he’s starting to think like, “Man, should we stick with this provider or not?” He says they’d probably be fine without it, but it would increase the Medicaid side probably a lot more to make up for it. So he just kind of finishes this question with, “Where do I begin? Who do I talk to? Maybe I should enroll in another, a different insurance company we’ve never used before?” So that’s kind of the context of the question. Before we get into anything, any thoughts on that question? Is that common? Is that a common phrasing? The things he’s expressing, and that’s our first point. What are some of the things that frustrate dentists about PPOs?

Matt Hironaka:
No, I think that is common. I mean obviously this client is you’re working with, they’re a pediatric dentist, or a specialist. And there are some distinguishing things that I think specialty practices should keep in mind that might be different than a general practice. That scenario that you mentioned where primarily that practice is Medicaid, I mean that is where we see that. And depending upon the state in which that practice is operating, Medicaid payments can actually be decent. I mean when I say that, competitive as compared to what even some commercial paying plans may provide. So I think that’s part of the evaluation. I make some assumptions here. I’ll say that the other plan that that practice is participating as a PPO provider would probably be Delta or MetLife. I mean we’ve traditionally unfortunately have seen that those companies have been unwilling to engage in negotiating rates of reimbursement for practices.

Matt Hironaka:
Which is unfortunate, because I think that that’s part of the partnership. And we certainly try to represent the practices that we work with, with both of those companies and ask them to kind of change that stance that they’ve historically taken. Obviously we have a lawsuit filed by the ADA as well on behalf of an individual practice in a class of dentists all across the country and it’s against Delta, and all of their entities across the country. So we’ll see how that plays out. As far as whether they should join another plan, or get out of the plan that they’re in. I mean it really does depend on what the goals of that practice are. I mean, I’m sure when you were talking to that client about potentially their portfolio or their investments, you want to know what their goals are. And what they’re trying to achieve.

Matt Hironaka:
With some practices looking to diversify the PPO plans that they are in network with, as preferred providers, is something that they should maybe evaluate. Because you see that different payers may from time to time reduce fees or take a stance that they’re not going to provide an increase, or negotiate an increase in reimbursements. And so if all your eggs are in one basket, that can kind of place you in a difficult position where you don’t have many options.

Matt Hironaka:
But again, it goes back to what the goals of that practice are. And if reducing reliance on Medicaid is one of those goals, we’ll then evaluating other plans may be something that they want to consider, and seeing what reimbursements are being offered. And the nice thing with specialists, I think that there’s usually, for some of the payers they are offered a different fee schedule than what may be available to general practice dentists. And so that can be a benefit to them. And there’s some other options as well depending upon maybe not a contract with the payer directly, but through one of the net network aggregators or third parties. Companies like Careington, Zelis that have some better fees, or even a percent off of UCR can be a good way.

Ryan Isaac:
So thanks for that man. So kind of like hearing some of his complaints, would you add anything else to the list of common complaints that you hear, or that are people just frustrated by PPOs?

Matt Hironaka:
Well, I mean, I think there are certainly many practitioners and just practice personnel out there that are little frustrated with obviously feeling like the rate that they’re being paid by the insurance companies, the reimbursements, aren’t in line with the cost of what it takes to provide high quality care. To pay good people at your practice to get new equipment and technology. And so, I mean that’s certainly probably the biggest frustration that we hear is that the rates of reimbursement have not increased in some time. Or they don’t seem to be at least catching up to what the cost of providing high quality care. Which the dentist wants and the insurance companies want for their insured members.

Ryan Isaac:
Long-term that should be money saving for an insurance company to have their people providing better care.

Matt Hironaka:
Yeah. Well I mean again, I mean the insurance companies, they’re businesses. And that’s how we encourage our customers to think, they’re businesses too. And so you have to make business decisions and I know it can be frustrating because dentists, unlike some other industries, I mean, if they’re not producing, they’re not making the money. So it’s certainly a lot more personal. But I think they need to evaluate things in a business mindset. And making sure that they understand the decisions that they’re making, and they are making them consciously. Right? Which kind of gets us into another frustration that they have, is I think a lot of dentists at times may not fully understand how they participate with each PPO insurance plan when a patient comes in the door.

Ryan Isaac:
What do you mean by that? They don’t understand, that was one of the points. Like maybe that’s the point of how does a dentist manage their PPO participation? So what do you mean by like they don’t… What are the things they don’t understand that they probably should? Or someone should in their office.

Matt Hironaka:
That’s right. Well what do we see over the last, I mean 20 years actually or so, is that the insurance carriers, they have a requirement where they need to certainly have enough in network providers in an area to sell plans to members. They certainly want to do that. They when they sell a plan to a member and say, “Hey, you have access to these dental providers in your area that are part of our preferred provider organization.” And so in order to get access to more dentists, they’ve entered into agreements in relationships with each other. And also these network aggregator companies, we call them umbrella network companies. There’s a couple of different ways to call them, but that’s again the Careington, the Zelis, the Connection, DenteMax and other groups. And so because of these relationships exist, and change, and new ones arise. Most recently there was announced that for some doctors that Ameritas had entered into relationships with both Guardian and Aetna, so three large payers.

Matt Hironaka:
And so where a doctor may be contracted with only one or two PPO plans because that bill is one or two PPO plans have shared their networks with other plans. They are now technically giving the same discount to other insured members of plans that they may not want to participate in. It can be both a good thing, or a bad thing. But what usually happens is they’ll get a letter or some notification. And when they get so much paperwork from insurance companies, or just other businesses.

Ryan Isaac:
You just ignore it over time.

Matt Hironaka:
Exactly. They may not fully realize-

Ryan Isaac:
It’s probably nothing.

Matt Hironaka:
They may not fully recognize how it’s going to impact them. And so I think that has occurred for many practices where they haven’t recognized that until they receive an EOB or some reimbursement. “Nope, wait, now Mrs. Smith is in, I have to give her the same discount, which she was a fee for service patient from my practice previously.” So, I mean, I think those cause frustrations, not really understanding how they participate with each plan and the changes that have occurred to their practice without recognizing it.

Ryan Isaac:
Well, I guess we’re kind of on the subject. This was some of the latter bullet points we were talking about. But maybe then what’s the process that a dentist should be managing this, I mean this is not a do it once and forget about it for the whole career kind of decision. So how do you manage this? Is this a dentist job? Should you outsource it, is an office manager job, do you just keep someone on retainer every month or every year? What’s the best way to do it?

Matt Hironaka:
Well, I think there’s multiple ways, and obviously the dentist, the office manager, office team members, there’s more than capable of doing the work. I mean, but it does take time and it does take understanding the information that they receiving. And making sure that they’re keeping it organized and again, understanding how they’re participating, and when they’re maybe eligible to negotiate higher reimbursement for their practice.

Matt Hironaka:
I mean as far as outsourcing it, why we have this kind of niche in the marketplace, is again, because it is time consuming, it can be frustrating. And where we can provide value, is again, understanding how these relationships work and where they can be either provide a disadvantage for a practice from a fee standpoint or maybe provide some different options for them. And then also staying on top of when they may be eligible for negotiations. Because the cycle is usually about every two years depending upon the insurance company.

Ryan Isaac:
I was going to ask that.

Matt Hironaka:
And if they’re not up to date on trying to do that, well there could be a year that goes by where maybe they were eligible for a three, 5% increase or more, and that they’ve missed out on for a period of time. It just takes time.

Ryan Isaac:
Is that common? I mean it seems, it seems like that’s your whole livelihood-

Matt Hironaka:
Yeah.

Ryan Isaac:
But it’s such a small detail that gets lost in the mix of all the other stuff that just gets forgotten a lot.

Matt Hironaka:
Well, it does. Yeah, it does. And I mean remember, a practice can go through different personnel and different doctors who may have previously been responsible for doing that work. Some doctors, I mean, I think this is now becoming more well known, especially over the last five years. And we’d talked to doctors that said, “I just didn’t know you could do that. I didn’t know that I could engage with them.” And so, I mean, it’s been left for a decade or more that where maybe they haven’t done that. But again, what’s the focus of a practice, providing great care and taking care of their patients and that’s the way it should be. This is kind of usually one of those functions that isn’t the priority at the time. And so that’s what we see.

Ryan Isaac:
So you said this earlier about, and I love what you said about first determining what is the goal of the practice first and foremost. And then figuring out like how do we implement everything around that goal to make that work. It might be heavier Medicaid acceptance. It might not be. It might be more fee for service, less PPO. Do you find, is it helpful when a practice is able to think about all these kinds of PPO, and reimbursement, and fee issues alongside P and L’s, and profitability, and managing like the services they’re trying to do, they want to do more of. They want to incorporate more implants or whatever perio treatment. Should this be like hand in hand with your profitability analysis and P and L and all that kind of stuff?

Matt Hironaka:
Yeah, I think it should be, I mean our scope is limited to the participation with PPO plans and reimbursements. But I really think, I mean practices, if they don’t feel the competence level on their own, they need to have a team working with you. Working with maybe another profitability coach on kind of the clinical aspects of things. And evaluating utilization where they may be missing opportunities to get more treatments accepted, or provide care that patients need. And how we work with your team and making sure the patient understands what they need and accepts that treatment. On our side, we can do what we can to help the practices make sure they’re getting reimbursed at a competitive rate for the services that they’re providing to those insured members. So I do think they should all go together sometimes. They don’t need to happen all at once, but I think they need to be connected in some degree so that again, you have a consistent and congruent plan moving forward.

Ryan Isaac:
Okay. So maybe we can round this whole thing out with the logistics of going through this process. There’s a few questions that stand out about what should you consider before joining one and what should a dentist keep in mind when evaluating maybe one they’re already participating with. But let’s just walk through from scratch. A dentist similar to the email I got this morning, calls you says, “Let’s just get started, walk me through the logistics of like how this actually works and gets implemented over the first few months, and a year out.”

Matt Hironaka:
You bet. So in the case with the client who emailed you, I mean we would probably categorize them into our evaluation, the program we call Flashlight Evaluation. We try to shed light on the PPO plans that are available to them and what they might consider. And what the reimbursements would be if they were to move forward. Because they’re only with one plan and they’re otherwise with Medicaid. Which unfortunately we don’t work with government programs because in each state there’s just different requirements. And we definitely don’t want to do anything that would cause issues in that area.

Matt Hironaka:
But we can certainly help them evaluate if trying to reduce reliance on Medicaid is one of their goals that they’d rather go the commercial payer route. So we’d have that phone call with them and again, just try to determine what they’re doing. We do a free consultation where we want to learn about them and describe to them what we do and whether it’s a good fit. That’s always important to us. We don’t want to bring on any customer where we don’t feel like we can help them achieve the goals that they’re looking for, or provide a return to them either through increases in reimbursements, or just an a return on their time that they don’t have to do this.

Ryan Isaac:
While on that subject, what’s an example of a practice that’s maybe just not a good fit for this type of a service, some kind of negotiation or analysis of their… Who’s not a good fit when you say that?

Matt Hironaka:
Well, so let’s take this client that you were speaking to. If they came in and said, we just want you to negotiate our current PPO plan that we’re in network with. And say it’s a Delta or MetLife, and that’s all we’re looking for. We’re not really interested in evaluating other plans, diversifying, or we don’t want to reduce what we’re currently doing with Medicaid. We would tell them, “I don’t know that the services that we provide is going to provide value to you then.” I mean, we know we can tell you if this is Delta or it’s MetLife. Historically they haven’t been willing to negotiate their PPO schedules. We can certainly make attempts on your behalf and see if where we can get, but I don’t know that that would equate to the service fee that you’d pay us for that program.

Matt Hironaka:
So whereas, if we had another of your clients that said, “Hey, I’m with every PPO plan. I’m contracted directly with all these payers, and I have other networks, and I’m not really sure how I’m participating with each plan. And I haven’t negotiated in the last couple of years.” We would certainly want to talk to them. And I think our PPO management service, which is geared towards helping them evaluate their current in network participation, their reimbursements, how they’re participating, and then trying to negotiate to increase reimbursements. And determine if they are with the right plans, and if they’re participating in a manner that is beneficial and practical from a standpoint of the patients that fall under each plan. And so in that scenario, if they felt like that’s what they were looking for, then we would engage them.

Matt Hironaka:
We would do an evaluation over the first 90 days. We review that evaluation with them. The comparison of their top codes that they make the majority of the revenue for the practice. How they’re participating, provide them a map so they understand with each PPO plan, is it a direct contract, or is it utilizing a network. And then where they may be eligible for negotiations with each plan. How long has it been, if it’s been two years or longer, we’d feel pretty confident that there should be a good opportunity to negotiate with that payer, depending upon who that payer is. And kind of lay out that plan to implement over the course of the next eight months or so. And then with each negotiation, show it to them how it compares to the current rates of reimbursement. And once they’ve accepted and it’s been submitted to the insurance company, to do check-ins on the EOBs that they’re receiving, that they would fill in information to let us know if they’re being paid correctly.

Ryan Isaac:
We wanted to take a break for just a second, remind you how easy it is to book a free consultation with one of our dental specific advisors. What you do, is you go to dentistadvisors.com and you’ll see a big green button that says book free consultation.

Matt Hironaka:
Can’t miss it.

Ryan Isaac:
Click that button and book a time that works for you. Or you can just call us at 833-DDS-plan. Let’s start a conversation about how we can help you with your finances.

Ryan Isaac:
You said something earlier too, kind of in the beginning of this process of like when you’re trying to like look at your fees and negotiate reimbursements or just make changes, compared to the codes and the services you’re doing. I’m sure that’s like an intuitive thing for most people, but that seems also like a pretty tedious process to actually go through and go, “What are we actually doing most of, and what’s actually profitable, and what’s not? I mean what does that entail?

Matt Hironaka:
Yeah, I mean I think the majority of dentists and the office managers, they understand as far as, “Hey, these are the codes that make us the most money.” But I think going through the process of going through that production summary, and identifying those codes, and making sure that that is what you’re utilizing to compare the reimbursements that you’re getting paid on those codes. And another thing, I mean as far as what dentists should keep in mind when they’re going through this process, is understand that your office fees, they play a role in your PPO reimbursements directly sometimes, and indirectly in a lot of cases. I mean, insurance companies, they’re trying to get a discount off of what the market rate for dentistry is, right? That’s a value that they provide to their insured members.

Matt Hironaka:
And so where they’re using that information is from the claim forms that practices have met. They should be putting their office fee on that claim form for the procedures that they’re doing. Well the company’s going to collect that information to determine what the market rate is, and usually the average market rate, and then a discount off of that. So as part of this process, they’re not evaluating their office fees, which they should be doing, I think at a minimum every two years at least. Because your costs of doing business goes up, inflation. So you should account for that and make sure that you’re making changes to your office fee schedule, what you charge people who come in off the street, don’t have insurance. That’s your market rate. You should be evaluating that as part of the process.

Matt Hironaka:
And usually first, because some insurance companies too want to know what your current office fees are as part of evaluating the reimbursements that they’re providing to that office currently. And whether or not to provide an increase or negotiate an increase. So I think it’s really important.

Ryan Isaac:
Is that the base of where it begins? To see where someone’s actual standard rates are first? And do insurance companies start there? Are they digging into that?

Matt Hironaka:
Well, I know they are certainly using that information, whether it’s aggregated data that they’re purchasing or collecting on their own to see where the market rate is for a certain area. Right? I mean some insurance companies may not look at that for a current office when they contact the provider relations representative say, “Hey, I’d like to have you review my current reimbursements.” They may not ask for that practice’s office fees or go through a full another evaluation of the marketplace.

Matt Hironaka:
They need to say, “Okay, here’s what I have available for your area, because they have certain parameters in which they need to operate.” But for some insurance companies as part of the negotiation process, they may ask for what codes you want to focus on, and what is your office fee for that specific code? I mean, here’s a point that we’ve seen with some practices that as part of the agreement that they have, the provider agreement with the insurance carrier, there’s a provision that says the dental provider agrees that they’ll charge the maximum allowable according to that fee schedule, or what their usual and customary fee is, and whichever is less. And we’ve seen instances where a practice’s office fee for a code is less than what the insurance company would pay to them. So insurance company’s going to pay that office fee.

Matt Hironaka:
And if that practice would have actually increased it, at least to what the fee schedule of maximum allowable was, well they would have been paid that. So that’s why it’s an important part of this process. I mean you’re just leaving money on the table that the insurance companies would pay you. Right?

Ryan Isaac:
Yeah. That’s interesting man. So kind of a long process. So to maybe just to round some of this out then. Is there anything else, if someone is maybe just starting to look at this on their own, they haven’t engaged someone yet. Is there anything they should think about when looking at the current PPOs? And maybe a startup who’s trying to figure out, “Okay, I’m just beginning, I’m getting credentialed. Who do I take? And who do I leave behind?” Any other like other tips for that?

Matt Hironaka:
You bet. So let’s start out with the practice that is already participating in network with multiple plans. I mean the first process I think, and again this is what we do. And so obviously I encourage a practice to go through this process if they’re doing it on their own. Is look at your office fees, look at your production summary, look at your top codes, collect all the current fee schedules from the insurance companies, or reimbursement fee schedules, and compare them with each other. So get an idea of what each payer is paying to you, and so that you can then kind of set a baseline. Know what percentage in network reimbursement you’re getting across your top codes from each insurance company. And so again, that when you go in, you can at least compare what you’re getting from each payer. When you’re going through the negotiation process. At least you have a good understanding of what you’re getting paid, right?

Matt Hironaka:
I mean, I think lots of practice kind of know generally, but when you get it down and that you can look at it and compare the reimbursements with each other, it kind of gives you a better sense of maybe where there may be room to negotiate with one payer. Maybe where you’re kind of higher as compared overall the average that you’re getting reimbursed. And say at least you have that data when you’re having discussion, and when you’re doing the negotiation process. And don’t forget to evaluate those office fees first. And if you’re going to make an adjustment to your office fees, do that before you engage in the process. So those are the tips that I would give to the practice. Again, you said they may seem kind of intuitive, but I certainly have talked to lots of practices that haven’t gone to that process first.

Ryan Isaac:
It’s time intensive man.

Matt Hironaka:
Yeah, it is.

Ryan Isaac:
That’s a lot of work. Okay. The same thing for a kind of a startup? What kind of things should they think through?

Matt Hironaka:
Well, number one, I think startup practices, especially the new builds, they need to start thinking about whether they’re going to participate in network with PPO plans very early. Lots of doctors don’t realize, they have so much that they’re trying to do with the new build, right? I mean, they got to get the property, you got to kind of set up their corporate entity. They got to get their webs… They’ve got to do all this other stuff, and they kind of forget about the PPO participation until they’re close to opening up. And the process of even just signing up with the PPO to be an in network provider is paperwork, and then the paperwork needs to be submitted with all the supporting documents, and then processed.

Matt Hironaka:
So if they don’t do that early enough, they may find themselves open and not in network with any plans for several months after they’re open. So start thinking about this now. Also, remember that many of the insurance companies will initially negotiate the reimbursement schedule. I mean, some won’t. Understand, there’s some companies that won’t negotiate, but many will. And they do want to work with the providers and make sure that they’re getting off on the right foot. So if they’re just accepting a fee schedule and signing up, they could have missed a pretty good opportunity for getting better reimbursements. Also, because there are these networks sharing relationships, there may be some opportunities that they want at least evaluate. And whether they contract directly with one PPO or use a shared network that two PPOs have together. And again that can be advantageous from a reimbursement standpoint.

Matt Hironaka:
And if they miss the opportunity initially to do that, trying to go backwards, meaning they’d have to terminate their participation with a plan is not usually a good scenario and has risks. And insurance companies don’t like it, and it can leave that doctor in kind of a tougher situation. That if they at least made informed decisions starting out. And again, this information is fluid and it changes all the time, and that’s why it’s hard for us. We’re just trying to act on the best information that we have at the time. But at least we usually have quite a bit more information than any individual doctor may.

Ryan Isaac:
So I feel like you could keep going. This is great. That was so much information. Let’s tie this up with how can people find you? How can they engage with you? What’s the best way for people to reach you guys?

Matt Hironaka:
Well, I mean our website, unitaspposolutions.com. There is information about the service programs that we provide. There’s an easy link to schedule a free consultation, and talk about what they’re experiencing and whether there’s some services that we can provide that might help them. I mean that’s really important to us that we have that discussion with them. And I mean unfortunately, we’d probably tell more practices than not that, “Man, we might not be a good fit for you. We want to make sure that it works.” And also we actually set up something as far as… Here’s really the call to action, I’d say for any listeners, go to unitaspposolutions.com/Reese. And we have a white paper there about some common issues, and hopefully good resources for people.

Ryan Isaac:
So that’s unitaspposolutions.com/Reese.

Matt Hironaka:
Yep, /Reese.

Ryan Isaac:
/Reese. As in Reese Harper, that everyone knows and loves so much, the big boss. All right man. Well thank you for spending so much time with us. I appreciate you lending your expertise and thanks everyone for listening. This is a fantastic episode and I really just appreciate all the great content here and for helping all the listeners, so thanks everyone. Thanks Matt, and we’ll catch you next time.

Matt Hironaka:
Thanks so much.

Ryan Isaac:
All right, Dentist Money show listeners, thank you for joining us today. My thanks to Matt from Unitas Dental PPO solutions for joining us on the show and lending his time and his expertise. What a broad range of topics and subjects, we could have gone easily another hour on this. So again, thanks for tuning in. Hope you enjoyed the show. We’ll catch you next time.

Practice Management

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