Going In-Network with PPOs: Should I Stay or Should I Go?

Many dental practices grapple with deciding whether to go in-network with insurance carriers. The decision will vary depending on many factors, from the affluence of your patient base to the diversity of employers (and thus PPO plans) in your area. There are many advantages to being part of PPO networks.

Pros of Being In-Network

• Simplifying the patient experience. Being an in-network provider gives patients comfort because it’s how most of them access care. An estimated 87% of Americans have dental plans, and according to the National Association of Dental Plans, more than 80% of those are PPOs. In its trend data reports from 2018–2024, the National Association of Dental Plans reports that more than 90% of patients with dental coverage in network-based plans use a dentist within that network. Accepting a patient’s PPO keeps them happier by lowering out-of-pocket costs. You also benefit from their perception that they’re receiving greater value from a preferred provider.

• Expand your patient base. Insurance companies use direct solicitations to encourage patients to choose their in-network providers. This resonates with patients looking for the best value. “Essentially, being in a network is a form of advertising,” says Greg Grobmyer, DDS, Editor-in-Chief of Practice Booster and Dental Coding with Confidence. “Being in a PPO network is a way to get your name in front of a large group of potential patients. That’s very appropriate for a newer dental practice or one that needs to fill more seats.”

• More consistent scheduling. Accepting PPO plans increases new patient flow and builds trust with insured patients seeking in-network care. Choosing an in-network provider gives patients greater confidence, resulting in increased patient volume and enhanced scheduling consistency.

• Improved treatment acceptance. Network participation can help facilitate increased acceptance of proposed treatment plans. The dental practice has visibility into the insurer’s portal to see what the patient’s out-of-pocket expenses will be, so they can give patients estimations fairly quickly. 

Cons of Being In-Network

• Lower fees. As an in-network provider, you may need to write off whatever the PPO won’t pay. “You don’t have to take the first offer the PPO plan makes to you, though,” says Dr. Grobmyer. “You have the right to negotiate fees or request changes to contract provisions. Your ability to negotiate will depend on the demographics in your area. If you’re one of the few dental providers in the area or are the one specialist in town who accepts that insurance, you may be able to negotiate a higher reimbursement.”

• Complexity. Working with PPO plans can be complex because they’re all different, even under the same carrier. Estimating the patient’s portion can be a bit challenging. However, practices that are out-of-network don’t escape these issues. “Out-of-network practices don’t have access to PPO portals, and this brings its own administrative headaches,” explains Dr. Grobmyer.

• Subject to the insurer’s rules. As a participating provider, you accept the regulations and restrictions of the insurance plan. “Fees can be negotiated to some extent,” advises Dr. Grobmyer. “There are companies, such as Unitas PPO Solutions, that specialize in negotiating these agreements and supporting dental practices with fee optimization when it comes to their contractual obligations as well as network optimization, which involves helping the practice navigate decisions about participating in an umbrella network or a direct contract.”

• Self-funded plans can be fairly restrictive. Fully insured plans fall under state laws and protect dental practices from onerous terms. However, nearly half of dental plans are funded and adjudicated by large employers. These self-funded plans don’t fall under these state protections, so they can dictate the terms, such as capping a claim or taking longer to pay a claim. 

Key Questions to Ask Yourself Before Joining a PPO

The decision about participating in PPOs doesn’t have to be an all-or-nothing endeavor. Many practices join a select number of PPOs that offer the best terms. When deciding whether or not to join a PPO network, consider these questions:

• Does my practice need support with filling chairs?
• Are the fee schedules sustainable? (i.e., Will you remain profitable on these reimbursements?)
• What percentage of my current patients are already in the PPO’s network?
• Will joining this PPO impact their current reimbursements through leased networks?

Questions to Ask a Potential PPO

For dental practices considering a PPO network, get a detailed understanding of the relationship in advance. Ask questions such as:

• How often can I renegotiate fees?
• Do fees change over time (for example, adjustments for inflation)?
• Can I participate directly and through leased networks?
• How does the PPO promote its in-network providers?

Making the Most of PPO Relationships

There are many ways to optimize the value from a PPO relationship.

• Let patients know. The greatest advantage of being in-network is that you’re a preferred provider. To increase PPO referrals, be sure your current and prospective patients are aware that you accept their insurance. Include this in all marketing, including ads, signage, and social media.

• Submit your full practice fee on claim forms, not the contracted fee. “If there’s more than one insurance plan at play, you may be able to receive your full practice fee between the two insurance companies,” advises Dr. Grobmyer. “Also, PPOs use the fees submitted on claim forms to establish what is considered usual, customary, and reasonable in your area. If you’re submitting low fees, not only are you preventing yourself from receiving a fee increase, you’re bringing down the averages for the whole zip code.”

• Learn about proper coding. Understanding how codes work and ensuring you are using the most current code set will enable you to maximize legitimate reimbursements. This way, you know you’re submitting the right documentation the first time, and aren’t leaving money on the table. 

• Optimize your participation structure. “Make sure your contract is set up well and that you are coding and reporting for all the different services you’re actually performing,” says Dr. Grobmyer. “That helps minimize write-offs and denials. Also, every time a claim is denied or kicked back, it results in administrative costs for you while your office staff chases down the claim. Be certain to have the correct patient information on the claim form and the appropriate documentation and attachments for the procedures delivered.”

Looking to learn more about PPOs? Check out our answers to frequently asked questions:

Q: What types of dental practices benefit from joining a PPO network?

A: New practices most commonly participate in PPOs to establish a patient base. 

“Starting a new practice that’s fee-for-service is very difficult unless it’s a very prosperous area of the country where patients don’t mind spending a little more. In most situations, PPO participation is advantageous, at least until you have a well-established, loyal patient base,” says Grobmyer.

The decision to participate in PPOs depends on different variables. If you’re in an area with one large employer, you may lose a large population of patients if you don’t accept their insurance. In addition, if you’re in a rural location or low-to-moderate income area, you may need to participate in PPOs to get enough of a patient base to support the practice. 

Q: Which provisions should I watch out for in PPO contracts?

A: Sometimes there are provisions for non-covered services where the PPO can actually cap your fee, even for non-covered procedures. Although there are laws in 42 states to prevent these onerous terms, these laws only apply to fully insured plans, not to self-funded plans, which instead fall under federal law through ERISA..

Also, look for clauses concerning the ability to balance bill your patients. Some contracts will state that the PPO can disallow certain services, making them non-billable to the patient. “You’ll want to minimize contract language around non-billable services,” says Dr. Grobmyer. “You don’t want the PPO dictating those terms if they are willing to negotiate the contract prior to signing.”

Q: How can I make sure being part of a PPO is worthwhile?

A: Reporting the full practice fee on claim forms is the first step. This helps you track the cost of participation in each PPO network. “Many dentists are hesitant about having write-offs, so they just submit claims with the contracted rate, but this removes the ability to track write-offs and the cost of participation with each insurer,” says Dr. Grobmyer. “There are reports you can run to see what percentage of your patients are on a particular plan and your costs associated with that insurer.”

Q: What are the risks of going out of network?

A: Going out of network will cause some loss of patients. “Don’t drop a bunch of PPOs at once,” says Dr. Grobmyer. “If you’d like to go out of network, carefully select the smallest PPOs that have the least effect on your patient base and start with those.”

If you do decide to drop a PPO, start a year in advance, so you have time to have face-to-face conversations with patients chairside to explain the reason for the change, that you can still see them as a patient, and that you can still bill their insurance. 

Have an advocate on your side

At eAssist Dental Solutions, we understand how complex PPO decisions can be, from evaluating which networks to join to maximizing profits to navigating the intricacies of dental coding. That’s why we’ve partnered with Unitas PPO Solutions to offer expert PPO negotiation services for our clients. Together, we help secure better fee schedules, optimize your participation strategy, and minimize costly write-offs. With our combined expertise and deep industry knowledge, we advocate for your practice’s financial success. Schedule a consultation today to learn how we can help strengthen your PPO position and elevate your bottom line.

Dr. James V. Anderson

CEO & Co-Founder, eAssist

Dr. James Anderson is a practicing dentist and the CEO and Co-Founder of eAssist Dental Solutions, the nation’s leading platform for dental billing. A serial entrepreneur, Dr. Anderson has built multiple successful ventures, including eAssist and nine dental practices in Utah, all driven by his mission to help dentists, their teams, and their patients achieve peace of mind. He co-founded eAssist in 2011 to give dental practice owners the ability to fully outsource their billing departments—a vision that now serves over 2,400 practices nationwide. Under his leadership, the company has formed strategic partnerships with the California Dental Association and Henry Schein, and earned a spot on the Inc. 5000 list for nine consecutive years. In 2020, Dr. Anderson was recognized as Entrepreneur of the Year by Business View Magazine and ranked among the top entrepreneurs in the country by Entrepreneur Magazine. He holds a B.S. in Finance from Brigham Young University, a D.M.D. from Oregon Health & Science University, and completed the three-year O.P.M. program at Harvard Business School. He also serves as Chairman of the Dental MBA Advisory Board at Roseman Dental School.