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

Don’t Make These Medicare Mistakes Like These Dentists March 02 2015, 0 Comments

(UPDATE: The Medicare Decision has been pushed forward until January 1st, 2106. This is still time sensitive)

The June 1st Medicare application deadline is almost here and it is incredible that I still meet dentists every day that tell me they don’t even know they have to make a decision.  Most dentists are now waking up and are in panic mode realizing how much they have procrastinated.  Over this past year, in my lectures and live patient training courses to over 10,000 dental professionals, I have heard many of the missteps that have happened to dentists concerning this Medicare decision. 

 First mistake is this – don’t wait any longer to get your application in.  Like simple supply and demand economics, the closer we get to June 1st, the more this is going to cost you!


 Ask any of your physician friends if they would attempt to apply to Medicare by themselves, they will look at you like you have lost your mind.

Let me ask you a question – do you prepare your own tax return?  Why not?  The form looks pretty simple, you can look at last year’s return and figure out what your accountant has done and just punch in new numbers.  You can do it, you can find all the information online and get questions answered.  You don’t prepare your own tax return because you would be a fool to do so.  In my opinion, any government application/form preparation including this Medicare application needs to be done by experts.

I will also offer this dental analogy – a patient comes in and asks for whitening.  You quote your fee of a few hundred dollars, take impressions, and the patient leaves the office.  The patient then goes to the drug store and finds out they can do their own whitening at a fraction of the cost, calls your office and is mad at your office for not telling them about the over the counter option and that you are a rip off.  What is your answer?  The same as mine – what we offer in our office is professional whitening, we take responsibility for it, we will do it right, and your chances for success are much higher.  The patient doesn’t listen, tries the OTC whitening, it works a little bit or not at all, and then eventually comes back to your office to get the results they really dreamed of.  The difference is now it cost them time and more money than before. 

The exact same thing is in play with this Medicare application process – some of the Medicare applications look so simple. I get emails and dentists come up to me after courses who have tried to go through the “simple” application process themselves.  

I asked the STATDDS specialists about the Medicare application process and was surprised to learn there is much more to this than just the application (which is why it is called a “process”).  There are letters back and forth from Medicare, there are updates from Medicare, determinations, rejections, corrections, reporting office changes, etc.  There is also a time period where you have to re-apply so that your Medicare status does not get de-activated.    

Nothing with Medicare is simple!


Miscues that dentists have reported to me concerning the Medicare decision that has happened to them over the past few months because they did not get professional help:

  • Dentists or front office staff try to do the opt in for prescribing application themselves – while it seems to be a short application, it is much more exacting that you know.  It is not just about getting the application right, it is what happens afterwards.  Many dentists have told me they have had this application rejected a couple of times (Medicare does not tell you where the mistake may be), and they have a real mess on their hands after spending countless hours on this. They have gotten Medicare letters they don’t understand, don’t know if and when the application is accepted, have waited months not knowing what to do and calling Medicare is like calling the IRS, good luck getting through and getting an answer.
  • Some dental associations have told members to opt out without fully understanding the implications - a number of dentists in a particular state opted out of Medicare and then were locked out of Medicare Advantage dental plans which they previously accepted and were happy with.  These dentists are now locked out of these plans with good reimbursements for two years and will directly lose patients who will not be back once this locked out time is over.
  • Some dentists make the erroneous assumption that if they do nothing, their patients won’t care because this is only about the patient’s ability to be reimbursed for Medicare Part D prescriptions which are cheap anyway.  This is a huge mistake.  This affects the patient’s ability to be reimbursed anytime you refer them for a biopsy, imaging or any procedure that Medicare may pay for in addition to their prescriptions.  If you know anything about Medicare geriatric patients, once they are told by a pharmacist that they have to pay even a small fee for a prescription because their dentist messed up, they will leave your office.  For every dentist that tells me they don’t care, I tell them to send the patients to my office.  These Medicare patients are doing more dentistry than ever before and I am happy to welcome them into my office.
  • Some dentists have mistakenly opted in for billing Medicare when this is not right for their office.  There are some minimum billing requirements they may not be able to meet at which time Medicare will de-activate their account.
  • Many dentists think “opting out” is the same as having nothing to do with Medicare.  They now realize this was a poor decision and have a ton of paperwork added to their daily dental practice which they were not aware of. 
  • Some dentists waited to process a separate Medicare DME application which cost them more money than bundling everything together. 

How much is your time worth? How much do you pay your front desk people?  Should a dentist be wasting their time slogging through the application? A few offices have told me they spent collectively about 40 hours on this application process including calling Medicare, trying to find out what is going on with their application, got a few rejections because of tiny mistakes, and they have no idea what to do or how they will know if their application is accepted. In lost production, your valuable time and your staff time which you are paying for, this can cost you $1000-1500, much more than letting professionals handle this for you.

Why did we choose STATDDS?  First, they were hundreds of dollars less expensive than anyone else for both the Medicare Part B applications and especially the DME application.  Second, they have the most experience with dentists and the Medicare choice.  I tried it myself for 2 ½  months and couldn’t get the application done, and my office managers are great at figuring things out. I wasted so much of my valuable time that I wish I could get back! We finally used the professionals at STATDDS to guide us and submit our application, we had our final letter from Medicare in 3 weeks.    

Because we enrolled early, we have already received our determination letters from Medicare and we don’t have to worry about the impending deadline.  We also submitted a Medicare DME application at the same time – this saved us money and more importantly time.  Using the STATDDS home bruxism and sleep monitor, our office has quadrupled the number of bruxism appliances and provides oral appliances for dental sleep medicine at a fee range of $2000-4000. Being a Medicare DME provider will significantly increase the number of these appliances our office will provide. 

STATDDS Statistics

Now that STATDDS has prepared so many dental applications, I asked them for some update statistics as to what dentists are choosing:

  1. 97% of their dental clients chose the opting in for enrollment option – this option, also known as enrolling for ordering and referring, is the best choice for most dental practices which is why it is the most popular.  As an ordering and referring provider, dentists will be placed on the Medicare Ordering and Referring Registry and will be able to prescribe medications as well as order and refer patients to Medicare enrolled providers and suppliers (such as blood tests, imaging, and the like) that will be reimbursable because you chose this option.
  2. 2% of dental clients chose the opting in for billing – these practices are the ones who provide services that can be billed to Medicare and medical insurance.  These are usually oral surgery practices or hospital based dental practices that treat major trauma and head and neck cancer patients routinely.  These dental practices also had to make choices regarding whether to be a participating provider, accept assignment, and will have to bill patient’s secondary insurance
  3. 1% of dental clients chose to opt out of Medicare.  The opt out option has the most continual relationship and paperwork over the long term, interrupts your patient workflow, requires Medicare patients to sign an intimidating document, and requires your office to do a lot of explaining to patients.  These dental practices are opted out for two years and are locked out of Medicare Part C (Medicare Advantage plans) some of which do carry dental benefits.
  4. 37% of STATDDS Medicare application dental clients also submitted a Medicare DME application at the same time for time convenience and savings.  Once a dental office is going through the process of Medicare applications, if they either already offer oral appliances for dental sleep medicine or will be in the next 2-5 years, then it makes sense to go through the DME application at the same time.

The bottom line that I tell dentists is this – do you do your own accounting or legal work?  Of course not.  This Medicare application process takes a certain level of professional skill and expertise which I guarantee that you and your front office do not possess.  The choice of which direction, application and provider status to choose requires careful evaluation, education, and professional assistance.