Navigating the world of dental plan contracts and reimbursements can be like reading legal documents written in Sanskrit through a tinted glass window. And yet the results can make a big difference in your write-offs and subsequent take home pay.
This is particularly true with companies that act as administrators/lessors and/or “networks” of dental plans. In essence these administrator networks sell and sometimes administer other dental plans.
The big question is which fee schedule the dentist will be paid from. This question arises because administrator networks and the dental plans which they sell have their own distinct fee schedules and often reimburse at vastly different rates. The difference in reimbursement for crowns alone can be in the hundreds of dollars. The point at which we attempt to determine the fee schedule used for payment is the point at which we jump into the rabbit’s hole.
When a dentist contracts directly with the administrator network she might be automatically enrolled with all dental plans within its network. Surprise!
To complicate matters, the administrator network may pay from its own fee schedule if the fee in question is lower than that of one of the dental plans within its network. However, what happens if the dentist is not directly contracted with the administrator network itself, but is contracted with one of the dental plans within its network? In that case he would most likely be paid from the fee schedule of the latter. To make things even more convoluted, at times a dentist is directly contracted with multiple dental plans sold within an administrator network, while not being directly contracted with that administered network. In that case, the fee schedule used for reimbursement is usually that of the dental plan which was directly contracted with first.
Most administrator network contracts state they administer and/or sell multiple dental plans (although they don’t always publish the full list.) Be careful, because they do not always spell this out. As a result, dentists could be paid from different fee schedules without even being aware that it’s happening, resulting in less take home pay.
You can opt out of unwanted dental plans associated with the administrator network after directly contracting with them, but it can take months for this to be finalized. In the meantime, most require the dentist to continue seeing their patients at the contracted reimbursement rates. To avoid this, you can opt-out of unwanted dental plans before directly contracting.
A key phrase here is “directly contracted.” Some administrator networks may attempt to auto- enroll (or contract) practices with the dental plans in their network without formal notification. Therefore, it is highly recommended to contact the administrator networks to find out if you are directly contracted with them, as well as with any dental plans they sell or administer. It is not uncommon to be told by the administrator network that you must reach out to a dental plan directly. If this occurs, tell the administrator network you first need to know if you are “directly contracted” with them. If they say yes, have them send you the fee schedule they are reimbursing you from (you could use this opportunity to opt-out of any of their associated dental plans.)
The next step is to reach out to any dental plans the administrator network may have mentioned to determine if you are “directly contracted” with them. This dental plan, in turn, may try to direct you to yet another dental plan, or back to the administrator. Keep in mind; however, that each one is responsible (and only able) to answer for themselves.
Most importantly, before contracting with administrator networks it would be immensely helpful to determine which dental plans are the most profitable for your practice. Having this information gives you control (and protects your take home pay) by allowing you to make informed business decisions about the administrator networks and dental plans you wish to work with.
For more information, check out Cobalt’s website at www.cobaltanalytics.net or call 801-953-9777.