Skip to main content
Toggle Menu of ADA WebSites
ADA Websites
Partnerships and Commissions
Toggle Search Area
Toggle Menu
e-mail Print Share

There's a way to negotiate for potentially higher reimbursement rates

January 11, 2019

By David Burger

Editor's note: This is the 22nd 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.

Nazareth, Penn. — To some dentists, it seems as if reimbursement levels from insurance companies are trending downward — and negotiating with those companies has become increasingly difficult.

Photo of Dr. Olenwine
Dr. Olenwine
Dr. Cynthia Olenwine, a member of the ADA Council on Dental Benefit Programs and dentist in northeast Pennsylvania, knows the feeling.

"Negotiating for the sole practitioner is almost impossible," she said. "Dental insurance is a difficult landscape to navigate."

Businesses that liaison between dentists and insurance companies are on the rise, promising to help dental practices improve their stagnant or decreasing preferred provider organization reimbursements through negotiation and optimization.

That's why Dr. Olenwine hired one of those businesses to negotiate higher fees from third-party payers.

"A negotiation and optimization vendor was very helpful in the ever-changing dental insurance landscape," Dr. Olenwine said. "Using an insurance vendor reduced my time spent reviewing contracts, credentialing, reviewing fees, et cetera," she said. "They took care of all those ancillary functions that were time-consuming and not profitable."

Best of all, she said, was that it allowed her more time to focus on the patient. "The reduction in the time that is needed to perform all the ancillary functions associated with being an insurance provider led to more patient and chair time," she said. "I was able to make informed decisions on the insurance programs that made sense for my practice. It allowed me additional time at the chair that is more productive than doing paperwork."

Nick Partridge is president of the Ohio-headquartered Five Lakes Professional Services, which, among other services, specializes in fee negotiation for dentists who seek higher reimbursement levels from third-party payers.

In an interview with ADA News, Mr. Partridge said that dentists choose companies like his to help providers negotiate their contracted rates.

"First, every business owner wants to realize as much of their professional fee as possible, "Mr. Partridge said. "Second, dentists invest significant resources — time and money — to manage the revenue cycle. As a result, there is a real cost to the provider to accept insurance. Next, as the number of Americans covered by a dental benefit continues to increase and more doctors go in-network, it puts pressure on margins. A majority of revenue becomes fixed in terms of contracted rates, but costs rise every year. Lastly, I think there has always been an underlying feeling amongst providers that insurance benefits somewhat dictate treatment and certainly affects patients' willingness to accept treatment."

Mr. Partridge argued that negotiating fees can lead to improved patient care when providers have more margin in their operating budget. "This manifests in many ways: time spent, materials used, staff investments in training, continuing education, et cetera. Providers should be able to do more and do better when margin pressure subsides."

DDB LogoMatthew Hironaka, chief operating officer of the Arizona-headquartered Unitas Dental, also talked to ADA News about its fee negotiation services, which is among a suite of services it provides to dental practices.

"The majority of dentists we speak with are very frustrated by what they consider to be the large write-offs they are required to take by participating in-network with PPO insurance plans," Mr. Hironaka said. "Dentists agree to discount their usual and customary fees often as much as 30-40 percent in order to participate as an in-network provider. This obviously has a significant impact on a practice's revenue and leaves dentists looking for answers to increase PPO revenue and improve profitability."

Mr. Hironaka said most, if not all, of his company's clients become more profitable after fee negotiation. "The vast majority of our customers experience an increase in their PPO reimbursements," he said. "The level of improvement in financials from year to year resulting from negotiated increases depends upon multiple factors, including the specific PPO plans increased and number of procedures completed by the practice and reimbursed by the plans. Many practices see a positive impact immediately following the effective date of the increase. For others, the impact of negotiations is realized in the future and when a specific employer group or larger group of insured patients switches their PPO plan to one where reimbursements were increased through negotiations."

Like Mr. Partridge, Mr. Hironaka added that his firm's services can augment patient care: "While most dentist and dental team members recognize that many PPO insurance carriers are willing to negotiate reimbursements, this process takes time and can be a little frustrating in some instances. Dentists and office team members focus on providing great care to their patients and evaluating and negotiating reimbursements is simply a lesser priority for many practices. Also, some practices may not know who specifically they should contact, how to go about evaluating their current PPO participation and reimbursements and how to evaluate an increase or what other options they may have for participation. All the dentists we speak to want to continue to provide the highest quality of care to their patients."

"If you participate in many plans, these services in my experience were invaluable," Dr. Olenwine said. "It allowed me to make better business decisions, based on information that would have taken me hours to obtain.  More time at the chair is a benefit to the patient as well as a benefit to the bottom line. Informed decisions by business owners benefit the patient and the office."

As an ADA Council on Dental Benefit Programs member, Dr. Olenwine noted that "third-party payer issues are the top-most concern for all dentists. The council hears about this all the time. However the ADA as an association legally cannot negotiate fees. It is up to the individual dentists to make business decisions. So at the council we are constantly developing tools and resources to assist dentists to provide high quality care and support thriving practices."

The ADA's online landing page for dental benefits information can help dentists address and resolve even their most vexing questions: 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 dentalbenefits@ada.org.

Previous installments in the Decoding Dental Benefits series are available at ADA.org/decoding.