Guest Blog

To PPO or not to PPO? November 20 2015, 0 Comments

by Dr. Louis Malcmacher

That is the question that dentist have been the debating for the nearly 40 years that I have been in dentistry. I would venture to say that while there has always been an anti-PPO sentiment and, if given the choice, most dentists would love to rid themselves of insurance once and for all, this is not realistic for most dental practices. I can tell you from our own group practice, and on behalf of many American Academy of Facial Esthetics (AAFE) members that I represent, many of us have chosen be in a number of PPO networks.


So if you are like our offices, how can you make the best of the PPO networks that you are a part of? The first thing is to realize that you don’t have to participate in every single PPO in your area. Before you sign up, careful evaluation is critical to see if the proposed fees make sense for your practice. Loss leaders do not work for private dental practices unless you are literally seeing many hundreds of patients from one particular PPO. Even then, it would be rare that this would ever make sense.


Once you have made the decision which PPOs to be involved with, how do you make the most out of this PPO relationship? Most dentists are unaware that they are able to maximize insurance reimbursement even with already negotiated PPO fees. You have already been locked into a PPO fee schedule so every single patient you treat under that fee schedule is going to determine a set procedure production. What if you could increase some or all of the fees in that PPO? That would mean that every single patient you treat would result in a higher reimbursement – meaning more profit for your practice without seeing any increase in patients.


Here is how this can be done – hire someone to negotiate an increase in the PPO schedules. I will tell you the truth we have tried to do this ourselves over the years. We would occasionally call up a PPO and ask for a higher crown fee or molar endo fee. To our surprise, every so often they would actually agree to our request. I know many of you have had the exact same experience and really feel good about yourself thinking that you were a master negotiator. Little did we realize, the PPO manager on the other end of the phone was getting quite a chuckle from our little “negotiation.” Essentially, the PPO manager had just thrown us a bone that, over time, really did not develop into any significant production increase. We did not have the proper information to ask for what would result in significantly more production. Not only that, we never thought to even check whether not that new fee schedule was, in fact, in place by checking monthly EOBs. We just assumed that once we hung up the phone, that was the end

of the matter and we would automatically get the increase. To our dismay, we never really saw any significant income increase.


Thankfully, we did find a professional team at STATDDS that handles PPO optimization management. This is the same company that handles Medicare enrollment for thousands of dental professionals and did a great job for us as well. These are real insurance professionals who understand what information is needed before negotiations with a PPO even take place. They also know what steps need to be taken to implement the new negotiated fee schedules so that we actually start seeing the increased insurance reimbursement. Their team has over 35+ years of industry experience including knowing how to perform demographic studies of patients and dentists in the area, UCR schedules, and knowing which and how many fees have the best potential for maximizing insurance reimbursement.


The negotiation time for the PPOs that we deal with was approximately 4-6 months at which time the STATDDS professionals confirmed that the new fee schedule was in place and that we were actually getting paid on the new fee schedule through their monthly contract monitoring. The best part of the arrangement is that they are paid solely on a successful outcome so if we don’t make more money, they don’t get paid. This insures that they work hard to optimize all of our office PPO schedules on a continual basis. I will take that deal any day as I know many dentists who have spent thousands of dollars with other companies and have nearly no results to show for it.


We dentists think that we know everything and so many times we overreach into areas thinking we are getting the best deal for ourselves. PPO optimization management is crucial to obtaining higher profitability in your office while not having to see one more patient. Outsource this to professionals.


The Medicare application deadline is rapidly approaching. According to the ADA, applications should be submitted by January 1, 2016 or as close to it as possible to allow for enough processing time. You can contact STATDDS at info@ or 800 693-9076.


Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author. Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE). You can contact him at 800 952-0521 or email Go to where you can find information about live patient Frontline TMJ/Orofacial Pain training, Dental Implant Training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, Botox and dermal fillers training, download this resource list, and sign up for a free monthly e-newsletter. Mention you are a TPD reader and STATDDS will offer you a special discount of $300 off Medicare enrollment and $200 off the activation fee for PPO Optimization Management. This offer is limited to the first 50 TPD