Bill Klaproth (host): This is an AAOMS On-the-Go podcast. I'm Bill Klaproth. And with me is Patrick O'Rourke, Founding Partner of Practice Quotient, Inc. And on this podcast, we'll be talking about deciphering and negotiating insurance network participation contracts. Patrick, welcome.

Patrick O'Rourke: Well, not only are we throwing confetti all over the place right now, the audience just can't see it, but this is what it means to you, money. So, forget about the confetti, pretend we're throwing hundred-dollars bills around and ensure money to your listeners.

Host: Well, this is a very interesting topic and a very important topic as you're here to save people some money, which is always a good thing. So, let's talk about this, what is the benefit of participating in an insurance network?

Guest: Let's separate it, we'll concentrate primarily on dental network because that's where most of the listeners' revenue comes from. So, why participate with a dental insurance network, right? Why become a participating provider? So, the theory is that for you, Dr. Bill, which would make your mom proud, if I'm the insurance company, I'm from the insurance industry, I would say, "All right, Bill. Listen, usually, you charge a hundred dollars for a service, right? So, you're going to give us a discount. And in exchange for that discount, you know, let's say it's 25% or as much as I could give, then in exchange for that, we are going to give you the promotional consideration of being on our participating provider directory website." Woohoo. I know, I see the confetti flying. We are going to route as many patients or members within our parlance patients your way, because now you're a participating provider and we want to send all of those folks to you because you're such a quality provider, Bill. And that's what we're going to do. And then for the patients, the patients, there's an expectation that you're going to be in network, we're the insurance company, so we're going to educate the patients and the members that they need to go in network. And depending on your region and how managed care-friendly it is, there's varying levels of expectation that you're going to be in network.

Host: Yeah. So in other words, this will help you increase or gain access to patients by participating in an insurance network. Is that right?

Guest: That's correct.

Host: So, this is a way to gain access. So, you're kind of widening the pool of people that can come see you. Is that a good way to put it?

Guest: That is how I would put it if I am the insurance company proposing network participation to you.

Host: So as you said at the beginning, we're going to drop some knowledge on you because we're going to teach you how to make some more money. So, increasing or gaining access to patients is definitely helping with that.

Guest: Right. So, let's think about it like discounting. Take the dental insurance part out of it just for a moment. There's only three reasons why you are going to discount your fees. And number one is to avoid empty chair time. Number two, for marketing, and it could be marketing gear on the website directory. It could be your referring general dentist expecting you to be in network. It could be you want to get your name out there and it will help your SEO. So, there's a marketing component to it. It's not free though. It is not free marketing. That's what people used to tell me years ago. If you're getting 60 cents on the dollar over a period of a year, you're spending $40,000 to get 60. That's the reality of it, you may not be writing a check. So then, the question is, is that worthwhile for you? Is that working for you?

And then, let's go back to the third reason. The third reason, and this is the good reason, ladies and gentlemen, and it is for referrals. You bring in a cost-conscious consumer, you're going to put yourself on sale, you're going to give a discount, and it's no different than a new patient or implant special or something if you're allowed to do that. And you say, "I'm going to be on sale," and then you bring in a cost-conscious consumer, and that consumer has an amazing patient experience over at Dr. Bill's. And then, they refer to either friends, coworkers, church congregation, neighbors, et cetera, and those folks are coming in because they care who puts fingers in their mouth or they care who puts them to sleep. You have a convenient location, the most amazing staff, and/or you have the best chairside manner in your state or they want to be cool like their friend who really cares. As long as they come in at full fee, that's the object of the game, so not everybody cares that you're on sale. So, that's the third reason, and that's really the good reason in my professional opinion.

Host: Okay. So, avoid empty chair time. Number two, marketing. Three referrals. So, keep those in mind as far as benefits of participating in an insurance network. So Patrick, are there certain factors that an OMS should consider when determining whether to participate with an insurance network? Like how many patients are in the network or how many OMSs are in the network or things like that?

Guest: I would say we want to base it, number one, on how much are you reimbursed based on your specific production. Even oral surgeons do different things. Yes, I know you all pull teeth, but what type of anesthesia you use, the volume of which you do them, coronectomies. So, there actually is a variance and it goes by clinician. So based upon what you do, you know, how much are you reimbursed relative to what you would normally be reimbursed if I walked in your practice? Because I would just pay your full fee. So number one, how much are you getting paid? That's really important.

Number two, how important is that network to your patient acquisition strategy? I.e., What's their market share? Is this important to your referring general dentist on a planned specific level? Like, let me use an example. Let's say you lived right by a military base, the Tricare DoD Program, you'd certainly be aware of it. And then on a very high level, how busy are you? If you're like, people can't get an appointment for six months, well, then you don't need a discount, do you, Bill?

Host: Right. No, you do not.

Guest: Right. And the third thing that comes up sometimes is, are they a good business partner for you? Now, I'm neutral personally. This could mean anything. So, that could mean they're making you do too many narratives and you don't like it, it's irritating you, or they don't pay their claims for 10 months or they're driving your staff crazy. Bottom line is nobody gets up in the morning to get dressed, drive to work, so they can sit on the phone with Acme Insurance Company, not mentioning any names, for two hours just to get the wrong answer anyway. So, those are the three major factors.

Host: So, how much are you getting reimbursed, remember that; how important is that patient to your practice overall, and are they a good business partner for you?

Guest: Right. The network, how important is that network.

Host: Network.

Guest: Right. So insurance companies, believe it or not, are not all equal. They go after different patient demographics.

Host: So, is it possible that there's too much of a good thing? Can you try to contract with too many insurance plans? Like, "This is great, I'm going to get with as many as I can." Is it possible to be contracted with too many of them?

Guest: A short answer is yes.

Host: Okay. So, why is that?

Guest: Well, let's go back to how busy you are. There's a lot of reasons. But I guess the primary reason, if you're doing it right, you're discounting for the reasons that I stated previously, it's for referrals and it's because there's patients in your area and because the fee schedule is attractive. If you're on every single plan, your fee schedules are likely not that attractive, and you're discounting all the time, even when you don't have to. So when you do a good job, the referrals that are coming in who may not care that you're on sale, right, they're coming in because have the best chairside banner and the best staff at a convenient location and the best equipment, and you've done all this continuing education. That's what they care about. They don't care that you're on sale, but then you're giving them a discount on top of it. So, you're discounting all the time. Long story short, that's one reason. The other reason is if you are on all the plans, you sign up on everything, you have very little leverage. You're also going to get repriced across the contracts. And so, say you are at a reasonable 25% discount, it will easily spiral up into the 35%, 40%, 50% discount. Now, you're losing money.

Host: This is true. Well, that makes sense. So, I know there are some contract clauses or words an OMS should be aware of that could have financial implications for the practice. I've done my homework, Patrick, preparing.

Guest: It does sound like that, Bill.

Host: I know. How about it? Things like silent PPO/rental network clauses, virtual credit card clauses, prompt payment clauses, non-covered service clauses. So, what do we need to be aware of when it comes to these clauses and other language that could be important to us?

Guest: I think you just hit the nail on the head. The industry in the world in general is an evolving, changing landscape. So, everything that was true even five years ago, the verbiage tends to change. But I would encourage folks, these are legal contracts, don't just hand it off to whoever gets paid the least on your staff and gets stuck with credentialing. You may want to read them. They're not that complicated. Although I would say those of us in the insurance industry speak Portuguese and the provider community speaks Japanese.

That said, there's a lot of stuff in there that may be adverse to your interests. And so if something looks funny and they're talking about how claims and compensation are, if you see the words repricing and if you see discounts and how discounts are going to be applied, that's in whenever you're checking boxes, like what are you checking? What are you agreeing to specifically? And if you don't know, you should ask the insurance company, they're happy to explain it to you about why you should discount that all the time. And because they want to bring smiles to the universe and they want to have the maximum annual benefit applied so they can get as much work done as possible, and why it's in your interest to take a bath from a financial perspective. You always have to remember whose interests are aligned where and/or you could talk to AAOMS or hire a professional consultant that can interpret some of these things for you. I would encourage you to do that. Now, a lot of the listeners here properly don't have the time. And then, I would say hire a professional to do it. And there's not going to be anything that says blatantly, " This section is where we rip you off."

Host: You mean they don't list that in there? What do you mean it's not in there Patrick? No?

Guest: It's not like, "Initial here. Please note we are taking your first born child as well."

Host: "Here's where we rip you off" highlighted. Okay. Thank you for pointing that out.

Guest: They're not all structured the same way either. And so, it could be by entity, it could be by provider, your claims repricing. So, one of the things when I'm educating is if you get a letter in the mail and it's like, "Great news," the dangerous language is in the middle. It's typically worded in a way. I was reading a contract earlier, so what did I see in there? Medicare Advantage, that's not necessarily bad, just be aware of it. In fact, it's probably a good thing these days. That's another story. The non-solicitation, if you drop their plan. And then, there's also the term like, "How long are you in there? Are you obligating yourself? How do you get out of it?" You need to look at that. And then also, the partners, how many partners are attached to this? Can they just add partners? How do they amend the contract? Can they amend the contract by just saying it out loud three times? Or do they have to notify you in writing? And how is that done? Do you have to agree to it? How are they amending the contract? That's a huge deal that everybody misses for some reason.

Host: I think those are some good tips. Make sure you read the contract if you have the time. If not, like you said, hire a professional. Make sure you're reading it all. And you said watch out in the middle is a lot of times where they're going to hide this dangerous language as you talked about.

Guest: Well, I'm not saying that they do Bill. It just happens to fall that way.

Host: Oh my goodness, yes. So, for the listener, I'm actually seeing Patrick now and he's nodding his head up and down as he's saying, "No, Bill, they don't do that." Right. And then, watch how they amend the contract. You got to be aware of that.

Guest: Very important. Anything that shows up is in writing. But these days too, they might send you a few different codes and it seems like this is a new CDT or the updated CDT for 2023. And it says, "Oh, please see the handbook and the other thing on the website." Nobody looks and that's where they just amended it and all the other codes are in there and they just dropped you by 20%.

Host: So, this brings up the point then. And you said earlier things change yearly, or you said the language we used five years ago is different than the language we use today. So, how often should an OMS review or even negotiate a managed care contract?

Guest: That's a good question. My position is firmly every minimum two years, and doing it every year is silly. Maybe you don't even need to do it two years. It just depends on the practice and your growth and what's happening in the market. I will say that the insurance industry has been evolving at a much more rapid rate than usual. And say we, because I say we sometimes, so forgive me. I do identify myself as somebody from the insurance industry. I know, boo, but we used to move at like a glacier-like rate. Now, it's moving much more rapidly. But you know, I think that the two-year rule is still good, and the reason for that is two years is a minimum amount of time for data to be credible in the underwriting process. So, it doesn't do any good to negotiate the highest fee schedule in the world if they cannot put patients in your chairs.

Host: Well, that makes sense. So, do you have tips for negotiating terms or better fees then?

Guest: Sure. So, you need to understand your practice and what makes you awesome. And so if me and Bill were right here and Dr. Smith came on, we'd say, "Listen, Dr. Smith. Why are you awesome?" right? "Are you dual degreed? How long have you been in practice? And why do patients choose you over other oral surgeons in your area?" If you don't really have a good rationale there, then we can stop.

Host: Right.

Guest: So, there's a lot of different things about what makes each independent practice awesome. And so, you have to understand your value proposition to the market, number one. Number two, you have to understand where your fee schedules are at, right? You know, are you getting paid appropriately? Are they trying to pay you like a general dentist? That's not nice. Understanding what your own value proposition is, right, and why people refer to you. You have to understand also what your leverage is. Each insurance company's different. They care about different things. Ultimately, they all care about how much they are paying out on claims on their contracts, right? And so, they're very good at it. There's a lot of mes over there, so they're waiting for you, so you better have a good reason why.

And I think, again, in the interest of time, what would I say to folks about what we do? I go, "Look, our job is to go convince the insurance industry that they need you more than you need them." Now, their job is to figure out whether that's true or not for them; not for me, not for you, Dr. Bill, for them. And so once you wrap your arms around that concept and you have your value proposition, always be polite. The folks on the other side are professionals, they are too. Then, you need to articulate the value and then be patient. And it's a process and it takes time, a lot of time. And depending on your state, there could be anywhere from 10 to 40 major payers. So the more that they are, the longer it's going to take.

You also need to know before you go there who you're contracted with. If I could say one thing, always keep these contracts, keep the fee schedules in a safe place or legal contracts, you can't dispute claims. But really, you should understand who you're contracted with and why, right? Have some reason. And then periodically, every two to three years, review that, whether you're using professional help or you're sitting down with your team and you're saying, "All right. Well, what's working and what's not working?"

Host: Yeah, that makes sense. So, know who you are contracted with.

Guest: Right. You'd be shocked, actually. I've heard all kinds of stuff.

Host: Well, I could see it's kind of a set it and forget it kind of a thing, and time just rolls on and two years rolls into four years, rolls into six years, and it's like, "Oh yeah, that thing."

Guest: And then, you're probably losing 3-5% on the back end. But I'm also talking about folks throwing away fee schedules. I remember this has happened before. Talking to a doc, he had three practices and I said, "All right. So, where's your fee schedules?" And he said, "I just throw them away. They just pay you whatever they want anyway." And I'm like, "You've been in business since 1986. You got like three practices, you're on DHMOs, this is going to take us a year to even figure this out." so, that's what I mean, like keep it organized. Don't just give it to your lowest paid employee that's volunteering for anything or has to take whatever crappy job they're assigned. It's serious stuff. It's your money.

Host: It's your money, that's right. And you also said know your value proposition, know how to articulate that as well. So, know your worth too. So, that's really important. Switching gears a little bit, can you give an example of a difficulty OMSs might face when billing dental procedures and what they can do to prevent it?

Guest: I think it's too broad of a question to answer in this type of format. But I will say this, a lot of times the providers will come to me and they say, "Well, this certain insurance company's doing X and this." And I'm like, "Well, how often?" Oh, this one patient one time back in 2008. Here's the bottom line, the insurance companies by and large don't care what's in the policy. And this is from somebody, I've sold millions of dollars of dental insurance. I could design my own plans and I've done it on schools, hospitals, stuff like that, right? I could go two years and that's still the same plan. If the client is the employer, if they wanted me to put in gold teeth, man, I'll put it in there. It's a financial vehicle, I just have to price it in. And so, the employer groups are the ones that are deciding and their benefit advisors. So, the consultants and the benefit, the licensed insurance broker/benefit consultants are the ones that are designing the plans.

Occasionally, you will have something like, "Can you pull a switch and then blanket deny third molars?" I'm not saying that that can happen, but it certainly could seem that way. And then, you just need to very politely and professionally go through the appeals process. They do track all of that. And so if you feel like you're unfairly getting targeted or you're having covered procedures denied for no good reason and it's happening across the board with a carrier and it's not employer-specific, then I strongly would encourage you to cry foul, right? If somebody's standing on my toe and I don't say anything and they keep standing on my toe, then whose fault is it? It's my fault. I got to say, "Hey, Bill, look, you're standing on my toe there, bud." Now if you don't get off my toe and you turn around, look at me dead in the eye and keep standing on my toe, now we have a different situation, don't we?

So, the insurance industry and the insurance companies, they have loads of consultants to come in, right? And they have folks from different sides and they're like trying to bring the cost of care down. And I used to be over there. And so, you're in a boardroom, you come up with different ways and see there are all kinds of crap against the walls to see what sticks, right? If nobody cries foul, there's no market feedback, then we think you like it. So, it's important to respond and say, "No, that's not going to work, right?" That's the way that the folks in the boardroom know. How many grievances did we get that? So if there's nobody that cries foul and nobody that says, "Aye, that's just not right," then they'll keep doing it.

Host: Right. Get off that toe.

Guest: Right. Exactly.

Host: How about what's happening where a patient's medical insurance for a dental procedure has to go to the patient's medical insurance before even being considered. Is that a big problem?

Guest: It's periodically a problem. It's a stall tactic in my opinion.

Host: Are there ways around that or things we should know about with these dental benefits being embedded in the regular medical benefits?

Guest: That's a good question. The dental benefits aren't really embedded in there, so to speak. I mean, if you're looking at the ACA, it's the PDO benefits that are in there. So, again, you kind of have to cry foul, especially if you're contracted and you got to look. That's what I think is happening a lot. And I need a little bit more information. So, you know, maybe AAOMS could sit down with whatever committee, say, "All right. Well, this is what is the non-participating providers that it's happening to. And this is what they're making them do, and it's happening more and more either on this procedure level or maybe on a carrier level." I don't think I have enough information on that, but it's definitely something that should be watched.

Host: So Patrick, thank you for your time. This has really been beneficial. Is there anything else you want to add? The floor is yours.

Guest: Floor is mine. Well, super. Well, if you don't get enough of my compelling rhetoric here, you could always check me on Dental Business Radio. And I will be speaking in San Diego 2023 this year. And if you like the content, be sure to tell AAOMS because I love AAOMS and I love all of the oral surgeons that are members of AAOMS, which is all of them.

Host: All of them.

Guest: Again, it is your money. And I'm not talking about a small amount of money. I'm talking about large amounts of money. And if you talk to any of our clients, they will tell you.

Host: It's worthwhile to make the effort to pay attention to this.

Guest: Right. If you don't, you will lose over a 10-year period a million dollars minimum.

Host: Whoa, there it is.

Guest: So, I'll leave you with that.

Host: That's how you wrap it up. Well, Patrick, thank you again for your time. This has been a lot of fun.

Guest: It's my pleasure, Bill.

Host: And once again, that's Patrick O'Rourke, founding partner of Practice Quotient, Inc. Practice Quotient is an AAOMS Advantage-approved partner that specializes in helping OMS practices with national managed dental care contract negotiations. For more information, visit aaomsadvantage.org or you can email This email address is being protected from spambots. You need JavaScript enabled to view it.. That's This email address is being protected from spambots. You need JavaScript enabled to view it.. And if you found this podcast helpful, please share it on your social media and make sure you subscribe, so you don't miss an episode. Thanks for listening.