It’s Time to Get Out-of-Network… NOW!

Last updated on March 29th, 2023 at 01:07 pm

If you participate in any PPOs, HMOs, or other discounted fee plans, should you stay in-network?

No.

If you were to ask me this question a few years ago, I might not have been so definitive. Maybe I would have at least urged you to drop the plans that reimbursed the worst.
I’ve changed with age. And the last two years haven’t helped either.

All joking aside, we can’t guarantee what the future holds, but it’s becoming apparent that dentists who continue to stay dependent on insurance plans are potentially in for a rough ride. And while getting out might be a lengthy process for your practice (depending on your level of involvement), you might want to think about starting that process sooner rather than later.

RISING COSTS WHILE BEING IN-NETWORK

I was speaking with a Power client during a seminar break not that long ago about his quest to find a hygienist. His office is in a major metropolitan area, so I expected the requested salary to be at the higher end.

What I heard floored me.

One wanted $68 an hour. The other? $70.

And what was the average hygiene salary for his area in 2019?

$40 an hour.

Folks – that’s a 70-75% increase—In. Just. Two. Years.

And as you’d expect, this is not an isolated case. I’ve taken to surveying hygiene (and other) salaries when I’m lecturing and all of them are rising meteorically.

And this increase in costs is not limited to salaries alone.

Just this past weekend I was speaking with another client who told me that two of their labs had just bumped fees by over 14%!

So, yes, costs are going up. All over. And if you needed any further proof beyond what you’re spending on food, gas, employees, labs, etc. the annualized inflation report for January of 2022 puts the overall inflation rate at 7.5%—the highest in 40 years (since 1982). So, if you were wondering why other businesses and prospective employees are asking for more—well—it’s costing them more to survive.

So, the answer of course would be to raise your fees, just like everybody else, right?

Yes—you should, and we’ve talked about that here at MGE a lot. On our blog, in videos, our podcast, and every time I give a seminar.

But…what if you’re participating in PPOs or other discounted plans (e.g. HMOs, etc.)?

Well, there you have a problem.

And the size of this problem depends on how much you’re participating.

PLAYING THIS FORWARD

Let’s use that client example I mentioned above. If he were to hire a hygienist at $68 an hour and charge normal fees for his zip code, he’d come out all right.

For example, in his zip code a cleaning, four bitewings and a periodic oral exam costs $308.

Assuming this $68/hr. hygienist sees one patient an hour, that would put his hygiene salaries for that hygienist at 22%. Not bad.

But what about a dentist that is “in-network?”

Just for fun, I looked at what MetLife paid for his area. He’s not in this plan, but other dentists in his area are. And you could assume they are in the same boat when it comes to hygiene salaries.

So, let’s say this $68/hour hygienist was seeing a MetLife patient. What’s MetLife’s reimbursement for that same prophy, bitewings and exam?

$131

Yes, $131 – a $177 or 57% write-off from the average full fee for that zip code. As a network provider in this plan, hygiene salaries would be 51.9%! That amount would be viciously destructive to a dentist’s bottom line.

How about an in and out-of-network crown? Met Life Fee: $825. Average full fee for that zip code? $1,400. A $575 or a 41% write-off!

And don’t forget, labs are charging more. Your assistant isn’t taking a pay cut for this procedure, and neither is your landlord, the power company or your Schedule Coordinator that scheduled this patient.

And look, I know some PPOs pay more than this MetLife plan. But how do any of them compare with your full fee?

LOWERING REIMBURSEMENT

And what have some insurance companies done to help their participating dentists struggling under the pressure of soaring inflation?

Lowered in-network fees and reimbursement.

Yes, lowered fees.

Instead of a life preserver, they’ve figuratively thrown a piano to someone that’s drowning.

I began hearing about this phenomenon in mid to late 2021 and couldn’t believe it. I don’t monitor every PPO in the United States, so sure, some may have increased fees, but the fact that anyone lowered them is absurd.

And to be clear, I don’t blame insurance companies for all of this. This is their business model. I don’t particularly like it, but then if I don’t like dealing with a business, I work out how to end my relationship. And for the long-term—I’d suggest you do the same.

I think what best illustrates the problem with all of this is that if you want to raise your fees in your business and you’re in-network—it’s just not your call. At least not for the in-network segment of your patient base.

As a business owner, this is just not good. You’ve effectively surrendered control over a part of your business.

GETTING OUT

Getting out of insurance plans may take time. Especially if they comprise a large portion of your patient base.

And sure, you could have your fees renegotiated (there are companies that do this), but to be honest, I wouldn’t look to this as a long-term solution.

The long-term solution is just to get out. And the sooner you get started, the sooner your practice becomes fee-for-service.

How to get out of plans would be dependent on your individual situation. Most notably:

1. The number of plans in which you participate,
2. The percentage of your patient base in plans and,
3. Your skill level with regards to marketing, treatment acceptance and management.

“1” and “2” above are obvious issues, for example, you don’t want a practice that is 90% PPO just dropping out cold turkey without a strategy to keep the practice busy. They might drop plans gradually.

With regards to “3” above, that’s what can make or break your office. If you’re going to run a business, you have to know how to bring in new customers, get them to buy what they need, and put together and manage a great team for growth. Especially if business growth is no longer driven by having your name listed on the PPO website or in the “book!” And that takes time and commitment, as many MGE clients who have done the MGE Power Program can tell you!

THE GOOD NEWS

When dropping a PPO plan, what’s the average percentage of patients that leave a practice?

Thirty percent. (30%).

(Note: with HMOs this percentage would be far higher.)

In other words, if a dentist has 1,000 patients in their practice for which they’re an in-network provider, they will lose 300. And keep 700.
Now, you say – that’s horrible! Who wants to lose 300 patients! How would I survive?

Well, there are several factors I don’t have the space to discuss here—such as out-of-network patients that have gone inactive and could be reactivated. And new patient marketing that you should be on top of if you were to do something like this—but again, let’s bring this back with some simple math.
Using our in and out-of-network fees from earlier in this article, let’s play this out.

You have three in-network patients that all need a crown. The in-network fee is $825. If you were to do all 3, you’d produce $2,475.
Instead, you decide to drop the plan. Your normal crown fee is $1,400. One of the patients leaves the practice. So, you end up with two patients going ahead with their crowns at full fee. $1,400 x 2 = $2,800.

You produced more in less time, while also lowering material, lab and labor costs.

Now imagine this scenario playing out across your patient base!

YOUR FUTURE: A FEE-FOR-SERVICE PRACTICE

Creating a fee-for-service practice is entirely possible – we have plenty of clients who have already done it. And you can do it too.
Again, a word of warning, this might be a process. It could take some time. It really depends on your current situation. Doing this wrong could create excessive hardship on both you and your business.

You need a plan.

And to that end, we want to help. To schedule a free Practice Analysis, click here or call us at (800) 640-1140.

If you’ve been around me recently you know that I feel strongly about this. I want you to be successful, and that success becomes all the more possible if you have complete control of your business. The time to start is now!

I wish you the best.