PPO-leasing networks can lead to confusion, consternation
June 11, 2018
Editor's note: This is the 14th story in the Decoding Dental Benefits series featuring answers and solutions for dentists when it comes to the world of dental benefits and plans. The series is intended to help untangle many of the issues that can potentially befuddle dentists and their teams so that they can focus on patient care
Dr. David Urban, a Virginia-based general dentist, has seen how the growth in leased dental networks can mean unintended consequences for an individual practice over his 37 years in dentistry.
Often, he has seen that he has signed with one preferred provider network, only to find that his name is part of an entirely different PPO, with the only notice being an explanation of benefits letter after the fact.
"It's problematic," Dr. Urban said, adding that leased PPOs make it harder for him to budget for the future and clearly and confidently talk to patients about their financial obligation.
In some cases, Dr. Urban finds out about the other PPOs only after submitting a claim for services and receiving an EOB that hows a reduction to a contracted fee and restrictions against balance-billing the patient.
The ADA has heard Dr. Urban's concerns, and is going to bat for members like him, realizing the burden that leased PPOs often place on dentists.
"It's the marketplace today," said Dr. Mark Jurkovich, former vice chair of the ADA Council on Dental Benefit Programs.
"It's becoming more and more prevalent," said Dr. Paul Calitri, a Rhode Island general dentist and member of the Council on Dental Benefit Programs.
There are various types of dental plans that utilize leased networks, and there are potential advantages — and disadvantages — associated with these plans.
Some dentists want the benefits that can come with joining a dental network, like visibility and patient retention, Drs. Jurkovich and Calitri said.
But one of the disadvantages is that dentists who signed contracts with one PPO are sometimes surprised to find out that they were contracted with other plans — without ever having signed on to them. In an extreme example, a dentist who signs a contract with one PPO may inadvertently agree to participate with scores — or even hundreds — of PPO plans from across the country.
Other concerns with leased networks include:
- When portions of the network are leased, credentialing and quality issues may not be under the control of the primary carrier. Dentists may be credentialed to different standards or not credentialed at all, Dr. Jurkovich said.
- Oftentimes, the lessor carrier has no direct contact with dentists in a leased network. Contract and fee disputes, as well as quality control, are managed by the lessee carrier. As a result, there may be long delays in resolving any disputes, creating administrative challenges and enrollee dissatisfaction. Dr. Urban cited this as a problem, often finding it hard to contact the lessee carrier.
Leased networks may also confuse dentists about which fee schedules are in effect. Confusion in the provider's office can lead to patient dissatisfaction if the wrong coinsurance or copay is charged — which ultimately leads to lost business. "There is a common sense of frustration," Dr. Calitri said, as well as additional administrative burdens to practices.
Dr. Jurkovich advises that dentists carefully review EOB statements to confirm dental plan benefit claims are paid correctly per a dentist's contract and network.
Dr. Jurkovich also recommends that dentists go through contracts with a fine-tooth comb. They should be on the lookout for clauses on how the contract can be modified (including lease agreements) once signed and how much advance notice must be given if modifications are going to be made, especially when it comes to reimbursement terms and policies.
"The dentists need to know what they are signing," said Dr. Calitri. He advises that his colleagues carefully examine the affiliated carrier clause in the contracts, in particular. "They are bound by the contracts they sign."
There are plenty of ADA resources on the subject, Dr. Calitri said, that many members are unaware of:
- The ADA Contract Analysis Service for unsigned contracts is a resource for member dentists, a tool to aid them in understanding and analyzing proposed contracts. The ADA provides the service through dentists' state dental societies. "It's a great service at no cost to the member," Dr. Calitri said.
- An ADA webinar on the subject called The Growing Impact of PPO Leasing on Your Dental Practice will stream June 26 at noon CDT and will be posted on ADA.org by searching for the name of the webinar. Register before June 26. Dr. Calitri is one of the presenters.
- A 20-minute podcast called PPOs, Leased Networks and Your Practice: The Impact is available at the ADA Center for Professional Success and led by Dr. Jurkovich.
- A comprehensive list of questions to consider when reading a contract called "What every Dentist Should Know Before Signing a Dental Provider Contract" is located online.
The ADA has created an online landing page for dental benefits information that can help dentists address and resolve even their most vexing questions. Go to ADA.org/dentalbenefits, part of the ADA Center for Professional Success.
Staff from the Center for Dental Benefits, Coding and Quality can help dentists with dental benefits-related and coding problems, questions and concerns. Call the ADA's Third Party Payer Concierge at 1-800-621-8099 or email email@example.com.
Previous installments in the Decoding Dental Benefits series are available at ADA.org/decoding.