Watch Intro Series

Ben Tuinei Explains the Art of PPO Negotiation – Episode 41

How Do I Get a Podcast?

A Podcast is a like a radio/TV show but can be accessed via the internet any time you want. There are two ways to can get the Dentist Money Show.

  1. Watch/listen to it on our website via a web browser (Safari or Chrome) on your mobile device by visiting our podcast page.
  2. Download it automatically to your phone or tablet each week using one of the following apps.
    • For iPhones or iPads, use the Apple Podcasts app. You can get this app via the App Store (it comes pre-installed on newer devices). Once installed just search for "Dentist Money" and then click the "subscribe" button.
    • For Android phones and tablets, we suggest using the Stitcher app. You can get this app by visiting the Google Play Store. Once installed, search for "Dentist Money" and then click the plus icon (+) to add it to your favorites list.

If you need any help, feel free to contact us for support.

Ben Tuinei, President of Veritas Dental Resources, has worked with over 6,000 dentists across the country to negotiate fair and reasonable reimbursements from insurance carriers. Using Ben’s 7 Steps of Negotiation, dentists gain leverage against providers to get the highest fee schedules available. In this Dentist Money™ interview, he explains what it means to build an insurance profile, how to overcome payment objections, the procedures most commonly downgraded by insurance companies, and the biggest mistakes dentists make during negotiation.

Show notes:
7 Steps to Negotiating Fees video:

Podcast Transcription:

Reese Harper: Ben! It is so nice to have you, man.

Ben Tuinei: Hey, it is a pleasure to be here, big fan of the show, listen to it all the time. I have got to say, I am impressed with your setup, this is very professional.

Reese Harper: Well, we knew we were bringing you in! We couldn’t just slap this thing together! You have heard the intro and know who he is now. Ben, let’s jump right into the content and hear how you got started in the dental business itself.

Ben Tuinei: Absolutely, before I started in dental, I was working in private equity. My main skill set was high level negotiations. A friend of mine contacted me out of Phoenix, he was working with a large group practice out there and he asked me to come and start managing the insurance processes, but my primary focus and the reason they hired me was because they felt like they should be negotiating their reimbursements with third party payers. I accepted the position, it was a pay cut, but I still did it because I felt like it was an opportunity. As I started to negotiate a lot of the doctors that worked at this group practice that had private practices they started to get jealous and say, “hey Ben, why are we getting paid $1,000 a crown at the group but at my private practice I am barely making $600 on the same insurance plan?” With the permission of the CEO, I went and helped those doctors out on an individual basis and then the referrals starting to come in. I quickly realized that there was no business out there that provided that service. I eventually quit the group and started my business with the primary focus of helping doctors negotiate with their insurance companies. Since that time we have helped over 6,000 dentists nationwide.

Reese Harper: That’s a couple! I have noticed that you have been involved in this industry for a long time. You have had a lot of different jobs, I think people who see your background on our page on the website will really get a good sense of all the different levels of experience you have had. What I want to dig into today is to try to give people some closure on what this fee negotiation process is all about. Should doctors negotiate their fees? How do they do it? Does it work? When does it not work? When does it work?

Ben Tuinei: Absolutely.

Reese Harper: How does it work for me in a rural area? How does it work if I am in the metro of New York City? I also want to talk a little bit about your experience with having or understanding about how doctors can mix insurance and fee for service and how fee for service would work and why insurance is important? We are going to get into a lot of different stuff. Let’s jump in initially at least, and focus on negotiating fees. When does it work best and when doesn’t it work as well?

Ben Tuinei: We have to teach doctors exactly how they can go through the process to negotiate. I believe we are the only company that provides that education, well at least me, I have done this under two other companies that I used to own. I call it the seven steps of negotiations. It is very thorough and very detailed to where a doctor can implement those skills and be very successful if they have the time to do it.

Reese Harper: I think that is probably the biggest issue. You are providing the education with that transparency in today’s world is what it is all about. The doctor typically won’t spend the time to stay on top of it so it just makes sense to get some help with it. What are the steps that people have to go through?

Ben Tuinei: The first step is that you have to build your insurance profile. Much like if you committed a crime and you had to hire an attorney. The attorney would have to build a profile, conduct an analysis that is rarely conducted today, it is the S.W.O.T analysis. Identifying the strengths, weaknesses, opportunities, and the threats. When you look at your insurance department you have to look at it from a non bias place. You have to look at all of your opportunities. For instance, you have to look at your office fees and make sure that they are set in the right area. Over 80% of the clients I take on standard office fees are 30-40% below where they need to be. Then they ask the question, “why am I only getting paid $600 on these crowns?” That’s because you only charge $800 for the same crown. The insurance company wants a discount. So if your fee for service was set for $1,000 for the same crown then naturally insurance companies start to increase their payback. That isn’t all we do, but assessing your fee’s is very important.

Reese Harper: When you say build your insurance profile, is that the first step? You are talking about really understanding where all of your fees are at and then where your insurance penetration is at in your practice? Like how much comes from each place?

Ben Tuinei:Correct. Your third party payer sources, your revenue coming in from third party payers, you want to prioritize which insurance companies mean the most to you.

Reese Harper: Ok, so if I am doing a million in collections or let’s say I am doing $600,000. I don’t want to alienate anyone out there. Big or small it doesn’t matter people. Let’s say I am doing $600,000 in collections. I want to know how much of that is coming in without insurance and that might be, what do you normally see? Do they have big chunk that is without insurance?

Ben Tuinei: Most are less than 10%.

Reese Harper: Then you have 90% coming from PPO’s and then you rank them by the ones that are reimbursing me, or rank them based on my collections, or who pays me the best?

Ben Tuinei: I like to first rank them by revenue. There are some strategies in the insurance profile you can work with one under an umbrella that might pay a higher fee schedule. The basic example I use is Principle and Emeritus. Not two main carriers but most of the time Principle comes out with a higher fee schedule and if a client of mine has a lower Emeritus fee schedule we will advise them to drop Emeritus and restructure under Principle to get a 15-20% increase. That is a couple thousand dollars of extra revenue a year. Nothing big for that example, but when you look at all the other insurance carriers that do have an affiliation with another third party administrator the dollars add up. We did an analysis for a practice in Mesa, Arizona and we do them every month. But our first example that we came across was the practice that did $800,000 a year in collections. We restructured, we terminated contracts with insurance companies, and restructured for others with higher fee schedule. In the end, doing that, and directly negotiating made a $90,000 increase for that practice.

Reese Harper: Wow, that is crazy.
Ben Tuinei: So that is on an annual basis. Those are fees the last forever so long as you maintain that contract with that insurance company.

Reese Harper: My first step as ranking by collections or revenue. Who is paying me the most. Then there is direct negotiations, but what was the other thing you said?

Ben Tuinei: Indirect negotiations.

Reese Harper: That’s when you look at who is a subsidiary of another carrier and saying just don’t take that one anymore?

Ben Tuinei: For the listeners this may sound confusing, that is why you need to have some direction and education and guidance. I call it the spaghetti junction of confusion which is basically anything that has to do with how dental insurance works. You would be amazed if you sat down and took some time to ask these insurance companies how the relationships work with other insurance carriers and it opens up opportunities for you to really take a look at your contracts from a financial perspective. How do I get the best fee schedule from that insurance company? Whether that is indirect or direct negotiations.

Reese Harper: You said first build your insurance profile, and then there might be another thing after that? Is there Seven!?

Ben Tuinei: Yes, seven steps. Within the insurance profile there are six different layers. Part of that is assessing your office fee schedule, identifying your direct contracts with insurance companies, understanding the leasing arrangements that insurance companies have with each other, identifying your top billed procedures, understanding your style of dentistry as it relates to coding, part of that is understand the alternative benefits because sometimes you submit a composite on a posterior tooth and insurance will downgrade that to a silver or amalgam filling. Those things are very important in the initial analysis insurance profile because you want to know what you are negotiating. There are over 350 CDT codes, there are a number of alternative benefits that are commonly referred to as down grade codes. Those are codes that you want to focus on in the negotiating process as well, not all of the 350 CDT codes. Those are just a few tips on building your insurance profile.

Reese Harper: What is a downgrade? Why would I get downgraded?

Ben Tuinei: Good question. The appropriate term is called alternative benefit. In dental practices, we refer to that as a down grade.

Reese Harper: The official term is getting screwed though right?

Ben Tuinei: Yes, in a roundabout way. Technically if an alternative benefit is invoked the practice has the right to balance bill. Meaning they can collect the difference between the downgrade and the procedure that was actually performed. That is applicable in most states, there are a few states that do not allow that. If you do that make sure you are doing it legally. The alternative benefit essentially was originally designed to where if a non covered service was performed the insurance company would then use an alternative benefits as opposed to no benefit at all. So tooth colored fillings on your back teeth are typically not covered. Most insurance companies feel like silver fillings are a sufficient form of care so they will only cover that as a tooth colored cosmetic fillings.

Reese Harper: Does that happen with a lot of procedures?

Ben Tuinei: Yes, this is very frustrating to doctors. Surgical extractions on a patient’s plan may only cover simple extractions and that is an extra one hundred to two hundred dollars that the patient may have to pay or that you have to write off. The biggest downgrade that we are seeing now is scaling and root planing which is a perio related procedure. Over 50% of the adult public has gum disease according to the CDC, and yet insurance companies are downgrading scaling and root planing all the way to prophy. That is a basic cleaning. So the financial for doctors, that means that for four quadrants that is $1,000 downgraded to $58-$98!

Reese Harper: That’s huge! No wonder they don’t present that treatment as frequently as they might otherwise.

Ben Tuinei: Ya, we help doctors understand the legalities. For instance, if you were to perform a trophy on a patient that had gum disease the question is would you be considered for malpractice and the answer to that is yes. Therefore, why do you let these insurance companies bully you. The insurance company doesn’t diagnose, but basically what they are recommending is that you should have performed a trophy on this patient. We have tools and recommendations to help doctors overcome this and make sure that insurance companies are held responsible for those actions. Not only is it fee negotiations but how to appropriately negotiate and challenge insurance carriers and the types of decisions that they make when it comes to claims payments.

Reese Harper: That’s good insight, let’s go back to those seven things again. They seem really good to hit one more time.

Ben Tuinei: Yes, the insurance profile is the first step. That’s your build up. Think of it as crown prep.

Reese Harper: I am getting a spreadsheet together of all of my stuff, and my columns I have all of my carriers, and now I have got to get my codes down too and know how much my UCR’s are. When you said they are 30% below where they should be, did you mean where the market should be? How do you decide if something is low or not. Seems like that data is hard to get.

Ben Tuinei: Yes, that data has been difficult to obtain for many years. It has to be defined as what is usual, customary, and reasonable. In the past, insurance carriers defined that UCR. In 2009, an organization called fair health was created and that was created out of money from insurance companies. The state of New York sued all of the insurance companies for a number of reasons one being unfair analysis of what is defined as UCR. So fair health ( is where you go to get the right percentiles. That organization is a non-profit and their main mission is to be a consumer protection organization to give the public true information on what is usual, customary, and reasonable.

Reese Harper: Within a market?

Ben Tuinei: Correct.

Reese Harper: I imagine each market is slightly different.

Ben Tuinei: Yes, even here in Salt Lake City and Utah County will be different than each other.

Reese Harper: Interesting, this might be beyond the scope, I am now asking a question that I am personally interested in. How does fair health know what UCR’s should be right? If fees in a market are dictated by insurance pressure then how do they look at markets with high PPO penetration and say you know that is a really bad fee, this is where a UCR should be. Or do they just look at reimbursements and figure it out from there?

Ben Tuinei: Great question, part of that settlement between insurance companies and the state of New York was that these insurance companies promised to report to the fair health database on what the doctors are charging. Fair health gathers that information. Mind you that data is not 100% accurate because some doctors bill their own fee. On occasion they will send in the insurance fee. Fair health takes those numbers and then they do their own market analysis on a number of demographic facts that they put into their formula to come up with a good fair UCR.

Reese Harper: Ok, so they are using the doctors declared fees. So if all of the doctors are not updating their fees on a regular basis then we might have a slightly lower average. I guess that’s market though.

Ben Tuinei: That’s right. When I first started promoting fair health back in 2012, I know that more than half of the doctors received that message. We have been checking the UCR percentiles here in Utah on the fair health database and they have gone up over 15%. Does it make a difference? Yes it does. Some insurance characters are reimbursing doctors above $900 on a crown. Where in the past the average reimbursements were at $500 for a crown. We are making some progress from here!

Reese Harper: All of you up there in Washington and New York you just enjoy your fees that are above $500 for a crown! So build our insurance profile, then the next thing that you listed was..

Ben Tuinei: Building your insurance profile is setting your office fees and identifying your top procedure codes, and identifying all of the insurance companies you have direct or indirect negotiations with. Also researching how those relationships work, for example, If I am in network with Aetna…

Reese Harper: That is what you meant by leasing?

Ben Tuinei: Correct. You want to know all of those different affiliations so that you can make good decisions. Essentially the insurance profile is research. You research all of the potential opportunities in an effort for your o be able to sit down and structure. As for the question how do I get the highest available fee schedule for each of these PPO plans I deal with? Is it a direct or indirect contract. That kind of leads you into the second step which is identifying your leverage. Most doctors, in most communities, do not have leverage to negotiate. If you are in a rural community the standard for medicaid is a 25% increase over the nearest metropolitan fee schedule, so I use that argument when I am negotiating for my clients that practice in rural communities. Fees ought to be higher just because of the medicaid benchmarks. Group practices typically have a lot more leverage because they have a lot more data. They may acquire a practice that already has negotiated fee schedules and they can negotiate those fee schedule terms for other practices in their group that might be lower. Private practitioners don’t have access to that and that is why it is necessary for them to not necessarily collude but to collaborate with other non dentist entities or what the ADA refers to as messengers that may have that data. There are several organizations out there where you can get good fee schedule data and there are firms out there that can help you negotiate that. The second part, or leverage portions, is deciding whether you want to do this on your own or whether you want to hire a third party. If you do it on your own the best piece of advice I can give any dentist is that you have to engage in the negotiating process yourself. You have to be the face of the negotiation. You have to answer the call and at least acknowledge them. Never, ever negotiate over the phone. The reason why is that those people have gone to school to negotiate and they will give you a tough time. I always limit, even for myself, negotiations to email. That is because you can track the communication, it gives you time to respond to those insurance representatives and you are not put on the spot. You do not say something that you will regret down the road. When the doctors get involved the statistics that we see is that about 100% of them will all be successful negotiating with certain insurance companies. 5% of the front office team members are successful, but 100% of the doctors are. The reason why is because it is your contract with that insurance carrier and they take it seriously. It is part of your agreement with them for them to respond to their communications and them to you in a timely matter.

Reese Harper: That is good insight. What are some different scenarios or ways to engage third parties to negotiate. I can do it myself, and you are saying if you do it in house, and not have someone else in the office do it. Don’t delegate that to an admin.

Ben Tuinei: Correct. I treat this as a form of production if you are looking at a $90,000 increase, treat it seriously. You don’t necessarily have to do all of the busy leg work, but the direct communication with the insurance representatives you want to be the face of communications. It makes a big difference it makes a big difference in the results that come.

Reese Harper: And use as much data as possible to support your case?

Ben Tuinei: Correct. For endodontists that we represent, and I know some of the general dentists may disagree with this, they have associations that show the difference between when an endodontist does an initial root canal versus somebody else. The chances for a repeat are very low. A lot of endodontists out there use the clinical argument as to why they should be compensated higher than the general dentist for their specific subset of procedures. You want to look at everything from clinical quality down to demographics down to what you feel is the finest quality care we can practice. All of that counts.

Reese Harper: So don’t just send an email and say, “can I get paid more?”

Ben Tuinei: No. The other thing I will mention is that we have had doctors do that and they say, “Ben, it doesn’t work!” I tell them, you are not asking it the right way. We had another doctor that was denied over and over and over again from an insurance company that negotiates with us all the time. He finally put a letter together and he dropped over fifty “F” words. He just let his frustration out.

Reese Harper: Classy.

Ben Tuinei: A few days later he forwarded me the response from the insurance carrier who said, “hey, you know, do you talk to your mother this way? If you are going to talk to our patients with that potty mouth then you are not a fit for our network.” That is exactly what they said, and they dropped him. That was $300,000 worth of revenue form that carrier and then they also said we do offer out of network benefits, but because we are highly concerned about who you are as a clinician, we question whether your morals, and your clinical expertise is even up to date, at an acceptable rate we will not even pay for those things. These insurance carriers can play dirty and if you draw that negative attention from them then they will. Play fair, be professional, do not use profanity.

Reese Harper: Use good data to support your argument.

Ben Tuinei: That’s what it boils down to.

Reese Harper: So you are saying don’t really leave this up to my insurance coordinator in the office to figure it all out because the insurance carrier won’t take it seriously? Why do you think the result is better? Do they not feel like it matters as much if the doctor does not negotiate personally?

Ben Tuinei: It is a matter of contract. When you engage the insurance carrier, if you read the contract, there is a section that talks about communication. They engage in that contract with you directly, so they are obligated to respond to you by nature of that contract. When you hire a third party, every third party firm has the doctor sign an agreement saying they are their power of attorney, which is an extension of that contract that the doctor signed with the insurance carrier. Whether it is us or the doctor negotiating the results are pretty significant. The reason that the insurance coordinators do not see much success, and it is not a knock on them, they can be nice people who do great in their sphere of responsibilities, but it is just a matter of contract. The insurance carrier has a right to ignore whoever contacts them if you do not have power of attorney or you are not listed on that contract.

Reese Harper: If you just had a random sampling of ten people, how many people do you think would try to negotiate it on their own or just outsource it to their office manager. I mean, who would even think to do it on their own? My gut feeling is just to think they would say, “I’ll have my insurance coordinator or office manager to take care of that. Tell them to try and get this insurance carrier to renegotiate prices.”

Ben Tuinei: That’s right. That is the majority of the calls that we get. When we do our educational lectures across the country, it is typically the insurance coordinators and office managers that are there. They say, “well, this didn’t work.” I say, “you didn’t listen to the leverage portion. If you follow the steps you will definitely have success.”

Reese Harper: Then when you say, “the doctor has got to do it.” Then he says, “is there a third party that can do it? I am pretty busy.” What levels of engagement can I get from a third party? Some people might just need to know what to do and then they can do it. They would like to do it on their own. Or at a certain point, when people decide to stop mowing their own lawn and outsource if it saves them significant time loss. I used to mow my own lawn, so I am not ripping on anybody, but at some point you can buy your time back by having people do things for you. Most doctors that are listening to this are producing between $500-$700 an hour. They could negotiate, potentially cost effectively, if they are willing to be the ones to do it. If they don’t have time or they don’t want to then on an hourly basis it is definitely a lot less to have someone else do this for you, what levels of negotiation can I engage in with different third parties? It seems like it is either all or nothing sometimes? It seems like take it all over or we will not tell you any of our secrets. You just listed everything and are very transparent! Are there people out there that allow for different levels of engagement?

Ben Tuinei: The firms that we know that exist typically keep a lot of this information to be secret. They want the doctors to have no other choice but to hire them. My philosophy is different. I am a big believer that there should be a high level of education about how to negotiate. Some doctors do have the time to negotiate and some doctors prefer to negotiate on their own! Our message is whether you hire a third party or not, something has to be done. That is the only way to raise the ship of fee schedules for a lot of the doctors throughout the country. In any given community there has to be more negotiations that go on. If anybody is listening to this that wants to do it on their own, I am happy to send you a video that talks about the seven steps, courtesy of course, Reese here, I will give it to you for free. You can do it on your own or ask us questions and we can give you some basic guidance. For the rest there are a number of firms out there that are my competition. I embrace them..

Reese Harper: Well, you are a strong advocate. A supporter.

Ben Tuinei: I do like them! I do refer to some of them when we are over capacity because in the end I want to make sure that a client has the best possible experience and the quickest negotiation timeline as opposed to them doing it on their own and taking too long. I got a call, for example, a guy last week in Sacramento who it took two years for him to implement my seven steps. It takes most firms anywhere between 4-7 months to negotiate with insurance companies.

Reese Harper: It seems like the first step is pretty hard. It would seem difficult to do. At least for an outsider like me looking in. Comparing that profile and understanding the gaps in your own practice? That seems like something that would be reasonable to have someone else do that for you. It would take a lot of experience to ever know how to do that well.

Ben Tuinei: It is a lot of data collection. It is a lot of understanding of areas of the practice that most dentists don’t understand.

Reese Harper: Ya, what to even look for?

Ben Tuinei: I am not saying that to insult any of the listeners, a lot of this is really hidden information that you don’t see on a daily basis. It doesn’t show up on your day sheet.

Reese Harper: So ultimately, with your firm, can I pay for myself to have an initial analysis done? You get that dirty work done? Then I do some negotiation on my own?

Ben Tuinei: That’s right. We will do an hour analysis for anybody and that is our new patient exam. Which doesn’t cost any money. In the end we send a proposal out to the doctor that will list all of the opportunities the various different insurance carriers that they should either drop, join, or negotiate with and for those that have the time to do it we will send you the video as well. We do that a lot where we tell people, “look I feel like your office manager is really strong, I feel like our involvement may hinder some of the philosophies that already exist in that practice, which are very strong.” Again, our mission is to make sure that doctors hear about this and then they take action one way or another.

Reese Harper: I think it is really powerful stuff man. You have really hit a lot of stuff. I think the overall, one of the big take aways for me, is just being able to identify that this is another area of practice management that is not a huge expense to have help with but if it is not done consistently, if it is not done on a regular basis, if it is not done on an ongoing basis, then you could see the benefits of when you did it three years ago kind of taper off as your practice profile changes.

Ben Tuinei: That’s exactly right, so my recommendation is to do your profile every two years. You usually re-do your insurance profile when your insurance contracts are due to renegotiate which is usually every 24 months or every two years.

Reese Harper: Alright Ben, any last minute things you want to leave with everyone? Give a takeaway or two that is maybe the most important.

Ben Tuinei: Ya, I would like to address one of the things you mentioned at the beginning of the podcast. The uninsured patient base. Most practices have 10% uninsured. What we are seeing out there is that a lot of practices that are aggressive with their own internal marketing and that build their own in house dental benefit program. Part of our mission is to help doctors understand that the fee for service mentality is still alive and it thrives. We work with clients that have their own efforts and building their own patient base, 1,000 or 2,000 patients that come from their own dental benefit program. I mean if you are really frustrated with insurance and want to figure out how to pair back from those contracts and reduce the influence of insurance in your practice, my recommendation is to really take a look at dental benefit plan. While you are doing that make sure you negotiate your fees but there is a huge opportunity for most practices to replace or even build an echoed a patient base that is non insurance related and they could easily do that if they focus on some of the internal aspects of their practice.

Reese Harper: That is interesting. Tell me a little bit about how I can do that. I know a lot of people have tried to implement an in office membership plan. Sometimes they don’t know where to start in terms of what benefits to provide at what fee level. They don’t want to get stuck with over committing. Talk to me a little bit about what a sample membership program might look like for a general dentist.

Ben Tuinei: I refer doctors to generated over a billion dollars of revenue and that is membership plans only. It is a place where you can go and buy as a consumer, I can go and buy a dental plan, I can go and buy an insurance product if I want but mostly on that website, looking at it from a doctor perspective, you can see what different dental plans are and how they are structured. The one thing to keep in mind about, all the plans that exist there, have already done the research on price points. What the markets will bear in that zip code. What people will pay for dental benefit plan, what they are asking the doctor to give up. For example, if a family pays $200 for a dental plan what are they getting? A free cleaning, money off of a treatment? If you check out it will give you a good sampling of your own area and what is already being sold. The difference is that on dental, when a patient buys a plan there the money goes to the insurance company or to that entity. If you create a program similar to what is on that money will go to you. The other option is that you can take a look at the various different organizations that are out there. I like Jordan’s company. The boom cloud apps. They do a great job in building a plan for you. You look at that, you look at, it will give you some direction at least on where you can start and what the options are for your own in-house plan.

Reese Harper: Do these usually get billed on a monthly or annual basis? What is most common?

Ben Tuinei: It depends, I know a lot of offices bill one time per year. The thing that you want to keep in mind with any type of and I am going to use the word “sales” is that you want to eliminate the barriers to entry. A lot of practices will do a monthly payment that is 6,10, or 15 dollars per month. That mirrors what you would pay for dental insurance anyways and people can afford that.

Reese Harper: What is an expensive market on a monthly basis that you usually see. You said 6,10,15 would be basic plan or entry level. What do you usually see on the higher end, how expensive can these get before the patient starts feeling like, “I don’t want to prepay for that many services”. You could probably build in a lot of stuff. Next, what can I not include in my membership program.

Ben Tuinei: Excellent question. Price point, I have seen plans as high as $40 a month per individual but that comes with two cleanings a year, all of your x-rays are covered. The plans that are more expensive really mirror dental insurance. You have a co payment for all of the work you need to obtain that is pretty similar to what you would pay if you were insured regularly. Fillings for instance are a 20% co-pay off of the fee schedule that is associated with their dental benefit program. Crowns are 50% rather than 100%. On the higher end, the $40 per month plan that you see with in house dental benefit plan. Not an insurance product but an in house plan it looks just like dental insurance. On the lower end, we see plans going for as low as $3.00 a month. That just covers a discount. You get 25% off all of services or 30% of all services.

Reese Harper: Ok, so at the high end I might be getting two cleanings a year and x ryas. Then a discount that is more substantial off of anything significant like fillings or crowns. Primary services have a discount associate with it. A lower priced monthly plan doesn’t give me really any services in exchange for that it is just a discount off of my UCR.

Ben Tuinei: That is correct.

Reese Harper: Let’s say I am trying to build my in house membership program and I want to determine what kind of plan I want to offer. Do I have two options, three options, what is the general guideline that you like to see?

Ben Tuinei: I like going to the restaurants where the menu is limited because I think the perception from the public is when they seek health care, when they seek dental coverage, they don’t know themselves what they want. They don’t know what is best for them. My opinion is that you have to create a fee structure or plan option that is limited. When I built a dental benefit program for a group in Arizona, we only had one option. It is a take it or leave it. You can pay our full office fee or take it. When they would come in for a basic cleaning or an emergency visit we would charge them our full office fee and say, “hey, if you spend $125 on our dental benefit plan it will take care of that. So it is either you pay $125 or $300 for that benefit. Which one do you want?” It is a forced choice of buying the membership plan, oh, and buy the way now that you bought our plan you have access to so many different benefits. The reason that we did that was because we wanted to have pool of warm leads to market to. For this group, 25% of our revenue was from our own dental benefit plan. That was about $70,000 a month that came in on a combination of membership fees and treatment that the patients paid for. It was a pretty big deal.

Reese Harper: Ya, that is huge! What is the average general dentist patient base look like? In terms of number of patients, if you had to say an average. One GP average of number of patients.

Ben Tuinei: Since doctor, average, I would say best guess is 1,300 active patients.

Reese Harper: Ya, probably no more than 2,000. Let’s say that we have somewhere between 1000 – 2000 active patients. If I could get all of those people on a membership program that was paying me $20 a month, or $15 a month, it just seems like that is a good start to getting to the right place! It won’t replace all of your revenue. but it can sure create some stability and offset some of the insecurity or the lack of clarity I have off of what I am going to be reimbursed from all of my third party insurances.

Ben Tuinei: It absolutely does provide at least some more motivation for you to show up to work in the morning. You are not being controlled by a third party fee schedule in terms of how you get paid

Reese Harper: When does it become insurance and when is it a membership program? I can’t say if you pay this much I will cover everything for you.

Ben Tuinei: I have been told by insurance companies that it becomes an insurance product when risk is spread. You are collecting a premium from a number of clients and that goes into a pool to spread risk among that set of patients. As long as you are collecting a fee and that fee doesn’t impact or pay for services for other patients then it is not an insurance product.

Reese Harper: Interesting.

Ben Tuinei: You have to be very careful when you design this, and make sure that your insurance products are licensed and you play by the rules. has already done the research for you.

Reese Harper: This has been great advice, man. We have talked about UCR’s, in office memberships, fee negotiations, this has been a super unique and powerful interview. I really appreciate you taking the time. We will get all of your contact information up on our site so people know how to reach out and get in touch. Any parting thoughts you’d like to leave?

Ben Tuinei: No, that’s it. Enjoy the industry, I love working with this dentists.

Reese Harper: We are going to have you back on, but next time you do have to do the Haka.
Thanks so much, we appreciate it.

Ben Tuinei: My pleasure, thanks Reese.


Get Our Latest Content

Sign-up to receive email notifications when we publish new articles, podcasts, courses, eGuides, and videos in our education library.

Subscribe Now

Related Resources