{"id":6380,"date":"2015-10-05T07:30:55","date_gmt":"2015-10-05T12:30:55","guid":{"rendered":"https:\/\/digitalblogs.wpengine.com\/?p=6380"},"modified":"2019-09-30T18:53:44","modified_gmt":"2019-09-30T23:53:44","slug":"what-you-need-to-know-about-ppo-participation","status":"publish","type":"post","link":"https:\/\/www.cainwatters.com\/digitalblogs\/what-you-need-to-know-about-ppo-participation\/","title":{"rendered":"Understanding \u2013 and Avoiding \u2013 Two Potential Pitfalls of PPO Participation"},"content":{"rendered":"<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\"><strong>by Nicholas Partridge<\/strong><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\">To accommodate, and some would argue to capitalize, on the steady growth of employee interest in dental benefits, dental networks are working to expand the number of providers and provider locations in a network. To do, they are offering new consumer-oriented features, as well as more cost containment options for employers. These measures, along with other factors such as government legislation, competition within markets, or mergers and acquisitions, can trigger changes to the way a plan is administered, including contractual changes with providers. In most cases, carriers and networks are required to provide notifications with regard to certain changes, but it\u2019s not uncommon to see this communication go out at the last minute, or in some cases, after some change has gone into effect. And let\u2019s be honest, even if as a provider, you do receive these notices, how much of it do you or your staff really understand and ascertain what the implications may be?<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\">So what does it all mean? <\/span><span style=\"text-align: justify; font-family: arial narrow;\">The simple answer is that you want all of the benefits that come with joining a dental network like visibility and administrative support, but if you\u2019re not reading the fine print, you might be in for a few unwelcomed surprises that affect the way you do business.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\"><strong>Your best protection is you.<br \/>\n<\/strong><span style=\"text-align: justify; font-family: arial narrow;\">The insurance industry is changing more frequently and more significantly than ever before. As a result, the only way for you to know if, when or how your participation in a network, or your contract with the network will be affected by one of many possible factors, is by making a commitment to learning and understanding how and why insurance companies partner with dental networks, and how they can legally implement contractual changes that may not even be on your radar.<br \/>\nEnjoy the benefits of participation, but commit to being in the know about everything participation entails and where potential problems may arise. Being knowledgeable puts you in the driver\u2019s seat. You are your best protection against two of the most common PPO participation pitfalls.<\/span><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\">Enjoy the benefits of participation, but commit to being in the know about everything it entails and where potential problems may arise. Being knowledge and educated puts you in the driver\u2019s seat; it\u2019s also your best protection against the two of the most common PPO participation pitfalls.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\"><strong>Possible Pitfall #1: <\/strong>\u201cWho\u2019s Your Daddy?\u201d<br \/>\n<span style=\"text-align: justify; font-family: arial narrow;\">As competition among carriers increases, in order to provide benefits to employer groups, dental insurance companies have worked to establish network sharing agreements thereby quickly multiplying the size and reach of their network. Over the past few years, many insurance companies have merged, acquired other entities, or established partnerships with other networks to add unique, diversified providers. Ownership of contracts may be transferred, or you may be a part of more networks than you\u2019re aware. Following industry news is a good way to learn about these types of changes. Know your networks and what the implications of leased network agreements may mean for you as the provider.<\/span><\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\"><strong>Possible Pitfall #2<\/strong>: The \u201cLanguage\u201d Barrier.<br \/>\nAs insurance company partnerships proliferate, office staff must also understand and be able to communicate whether or not the dentist is in-network. It is difficult to estimate patient payments when offices don\u2019t have a strong understanding of which fee schedule they will be paid from which can make for an unhappy, and likely frustrated patient.<\/span><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\">Moreover, changes in how some carriers administer dental plans can create even more confusion. It\u2019s possible for carriers to make adjustments that allow them to pay off the lowest of the fees schedules among partners, or pay in accordance with some new partnership agreement, despite a signed contract based on a specific fee schedule. The legal grounds for this kind of maneuvering can be covered by broad language in insurance carriers\u2019 contracts with each provider that allows them to make changes that are \u201cin the best interest of the member\u201d. Guess who gets to determine what\u2019s in your patients\u2019 best interest as it relates to their dental benefits? Yes, the carrier. Again, careful review of the contract is critical.<\/span><\/p>\n<p><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter wp-image-6505 size-medium\" src=\"https:\/\/www.cainwatters.com\/wp-content\/uploads\/sites\/2\/2015\/01\/5-TIPS-TO-STAY-AHEAD-300x201.png\" alt=\"5 TIPS TO STAY AHEAD\" width=\"300\" height=\"201\" srcset=\"https:\/\/www.cainwatters.com\/digitalblogs\/wp-content\/uploads\/sites\/2\/2015\/01\/5-TIPS-TO-STAY-AHEAD-300x201.png 300w, https:\/\/www.cainwatters.com\/digitalblogs\/wp-content\/uploads\/sites\/2\/2015\/01\/5-TIPS-TO-STAY-AHEAD.png 337w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/p>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify; font-family: arial narrow;\">Like water finds the least resistant path when flowing, it\u2019s likely an insurance companies will find the lowest fee schedule through which to reimburse a provider. Therefore, it is important for dental office management to take the following measures to avoid any surprise:<\/span><\/p>\n<ol>\n<li style=\"text-align: justify;\">Always verify benefits before treating a patient.<\/li>\n<li style=\"text-align: justify;\">Ask questions and keep asking until there is a firm understanding of what impact any changes to the provider\u2019s contracting status as a result of a new partnership or other factors will have on payments.<\/li>\n<li style=\"text-align: justify;\">Be educated on the aspects of membership that have potential for contractual changes and aware of outside influences such as legislation and market competition, that may result in carriers making changes to the administration of your plan.<\/li>\n<li style=\"text-align: justify;\">Closely monitor the explanation of benefits for each claim to identify nuances and trends.<\/li>\n<li style=\"text-align: justify;\">Equip yourself with knowledge and prepare to take action if something isn\u2019t adding up, or work with a professional consultant to help oversee your PPO participation.<\/li>\n<\/ol>\n<p style=\"text-align: justify;\"><em>\u00a0<\/em><span style=\"text-align: justify; font-family: arial narrow;\"><img decoding=\"async\" class=\" alignright\" src=\"https:\/\/www.cainwatters.com\/wp-content\/uploads\/sites\/2\/2015\/01\/Nick-Partridge-150x150.jpg\" alt=\"Nick Partridge\" width=\"150\" height=\"150\" \/><em>Nick Partridge is the president of Five Lakes Professional Services, a Cleveland, Ohio based PPO management consultancy. For more information, visit <\/em><a href=\"https:\/\/www.fivelakespro.com\/\" target=\"_blank\" rel=\"noopener noreferrer\">www.FiveLakesPro.com<\/a>.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>by Nicholas Partridge To accommodate, and some would argue to capitalize, on the steady growth of employee interest in dental benefits, dental networks are working to expand the number of providers and provider locations in a network. To do, they are offering new consumer-oriented features, as well as more cost containment options for employers. These [&hellip;]<\/p>\n","protected":false},"author":7,"featured_media":6519,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":"","_ppma_block_editor_authors":""},"categories":[16],"tags":[],"ppma_author":[48],"class_list":["post-6380","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-digital-news-feature"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Understanding \u2013 and Avoiding \u2013 Two Potential Pitfalls of PPO Participation - Cain Watters Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.cainwatters.com\/digitalblogs\/what-you-need-to-know-about-ppo-participation\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Understanding \u2013 and Avoiding \u2013 Two Potential Pitfalls of PPO Participation - Cain Watters Blog\" \/>\n<meta property=\"og:description\" content=\"by Nicholas Partridge To accommodate, and some would argue to capitalize, on the steady growth of employee interest in dental benefits, dental networks are working to expand the number of providers and provider locations in a network. 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