Optimizing Dental Network Participation

What you don’t know could be costing your practice tens of thousands of dollars a year in lost revenue.

If you feel like you are working harder each year and making less, your practice’s network participation decisions could be the issue.

Dentists are participating in more networks than ever while benefit administrators (payers) are using more networks at the same time. It is not uncommon for a payer to use a combination of four to six networks (a practice called stacking) or for payers to exchange networks (known as swapping). The result is that your network participation decisions may be eroding your practice’s income from its existing patients.

Excluding proprietary‐only networks (e.g. Delta Dental), about 65% of dentists are available through existing networks, with an average of about six price points per dentist. This means that as payers optimize their stacks of networks, a practice’s reimbursement will gravitate toward the network agreement with the lowest fees.

A practice may agree to participate in a deeply discounted network, either to gain access to a handful of additional patients or to support a specific local group. However, it is more common for a practice to participate in a network that offers reasonable fees. After years of participation in the same network, with minimal to no fee increases, the discount for the practice will likely become unreasonable; however, terminating the agreement would be disruptive for the practice’s patients.

Optimizing network participation is the process of maximizing reimbursement while minimizing disruption to patients and patient flow.

Your practice should never sign a network agreement without knowing:

1. Will the network be leased to other payers, and does the payer use other networks? If so, which ones?
2. How many members are there in the practice’s area?
3. What are the plan designs?
4. Are the payer’s employer groups predominately large or small employers?
5. Does the payer recognize assignment of benefits?
6. How are the fees set, and how are they updated?

If a payer leases its network to other payers, uses additional networks (stacking), or exchanges its networks (swapping), it is critical for your practice to consider the following points:

• If the network is being leased to other payers, will these fees erode revenue from current patients.
• If the payer is using a stack of multiple networks, is your practice already participating in one of those networks? If not, which one could you negotiate the highest reimbursement from, and would you want to see these members at those fees? How would doing so impact the reimbursement your practice receives from current patients?
• If the network is being swapped, you should aggressively negotiate the highest reimbursement from both payers and terminate your practice’s agreement with the lower reimbursement. There will be no disruption for your patients.

By participating in a network, your practice is deciding to accept a discount in exchange for increased access to patients with dental benefits.

A patient with dental benefits is more likely to receive dental treatment. The number of members in your practice’s area, plan designs, and the size of employer groups are all critical factors to understand when deciding whether participation is the best decision for your practice.

Dental benefits are a relatively inexpensive way for employers to attract and retain their workforce.

• The larger the employer, the more likely it is that their plans will have the same benefits in‐network and out‐of‐network (called passive plan design or no‐benefit steerage).
• Smaller employers are much more cost‐sensitive and are more likely to have a lower out‐of‐network benefit (known as active plan design or benefit steerage).

Typically, the larger the employer group, the higher the out‐of‐network reimbursement. It’s easy for a practice to feel “forced” into accepting a deep discount on its services for access to a large and well‐known employer group. The decision to participate could mean a 40% discount off your practice’s fees, while not participating would mean your practice’s services are reimbursed at the 80^th percentile of usual and customary fees (note: 50^th percentile is the average charge in your area). With these details in mind, you must consider: What is the best choice for your practice?

It is essential to understand the payer’s current members, type of members (individual, exchange, group, etc.), and their growth strategies. Accepting a deeper discount to participate with exchange members might be a reasonable decision, while accepting the same discount to participate with group members may not be beneficial. Group members are predominately a zero‐sum game; accepting a deep discount for these members commonly results in revenue from current patients being eroded.

Recognizing assignment of benefits is more common than you might think, even when there is no applicable state law. When a payer does not recognize assignment of benefits, the practice is forced to collect the full payment from the patient at the time of service. This makes access to care even more difficult for patients, and it runs contrary to the objective of most employers in offering dental benefits.

When a payer builds a network, they typically use several fee schedules.

Their objective is to contract with as many practices as possible at the lowest fee acceptable to each practice. Once contracted, the typical fee increases are minimal; 95% of practices never even attempt to negotiate their fees each year. While there are networks that will not negotiate fees, there are many others that will. Continual fee negotiation is an important part of the process of optimizing network participation.

Employers with several hundred employees or more are predominately self‐insured. For these members, the payer charges the employer an administrative fee and does not assume risk for the claims. The primary value an employer looks for when selecting a payer is the discount (i.e. the difference between a practice’s billed fee and the payer’s allowed fee). Therefore, each practice must work to actively manage its fees in order to support its efforts to achieve reasonable reimbursement from payers.