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What are the benefits of PPO plans in dental billing and how does it work?

What’s the Difference between PPO and DHMO Dental Plans?
January 6, 2021

The dental practitioners are dealing with the preferred provider organization dental plan (PPO) in order not to lose any patients, and the PPOs are using this psychology to compel dentists to leave or to sign up. According to the provisions of the contract, the plan uses a network of dentists to deliver specified services to patients for set fees. PPO is the most popular type of dental plan and accounts for 74% of the total maximum benefit, despite excluding their certain services yet giving dentists more power than to reap the benefits. 

To attract new clients and maintain a healthy relationship with patients, dentists identify the gap between the collection and the production. The hard worker dentists are paid for the rendered services and are not working for free. Unequivocally, there has not been a reduction in supplies, rent, types of equipment, or wages for years. 

Peeling off the PPOs can fade the active patient counts irrespective of the level of service. First of all, this would lead to upfront pay since the insurer will send the benefit payment directly to the patient. Raising fees and charging up to the 90th percentile could aggravate some patients right away. However, in this context, it would confuse the patients. Perhaps, at worst, it will scare them off and not compensate for any patient attrition.

In this article, we will discuss the benefits of PPO plans in dental billing so that no matter what, dentists will not lose even one patient in dental production activity. 

Benefits of PPO plans in Dental Billing

  • To get a perspective on dentists who practice with a high number of patients is dependent upon a collection of factors like PPO dental plan, well-trained staff, prominent advertising, social media presence, visibility, expanded business hours, and modern equipment. 
  • To earn profits year after year, dentists need to manage the PPO participation efficiently. To elaborate, if your PPO represents 15 percent of your patient base and allows 60 percent of your standard fees. For example, if you are producing $100,000 per month, then $60,000 per month is your practice’s bottom line. That you can nicely keep adding if you learn how to deal with PPO decisions. 
  • Dealing with PPOs can get you great patients that you don’t want to mislay and balance your PPO participation that eventually slows down any loss of patients. 
  • PPO insurance gives flexibility to patients as well as to dental practitioners. Regardless of in/out-of-network dentists, 82% of today’s dental policies are under PPOs. Insurance companies create a network, and the contracted dentists under the web get more patients with set fees. Patients can contact any dentist outside the grid at a high-out-of-pocket expense. Furthermore, the patients are responsible for the difference cost between the dentist’s fees and the plan’s benefit payment.
  • A PPO plan ensures 100% coverage for diagnostic and preventive services, whereas percentages preconceived basis the plan allowance fees. 
  • Through utilization review (UR), both the dentists and the purchaser can evaluate the benefit from the PPO dental plan. This control mechanism has an impact on the dentist-patient relationship. With the help of utilization review, the dentist gets notified by the payer. In case the procedure going above the norm. To justify the different practice patterns in the area, the dentist has a choice to continue or change the practice pattern as per the UR norm. Additionally, if they dropped the plan and choose not to change the practice patterns, have the right to appeal is included in the contract.   
  • With the help of CDT codes, dentists under the contract can calculate the overhead cost and a reasonable profit in the market. 

How does the PPO plan work? 

With a PPO plan, preventive care services like x-rays, sealants, fluoride treatments, and annual visits are 100% covered, whereas the primary & extensive procedures like fillings, extractions, root canals, bridges, crowns, dentures, inlays, and treatment for gum diseases offset at a discounted co-insurance fee. These treatments are not essential to oral health and intend to improve the look of teeth. The patients can ask for the pretreatment estimate to prepare for the dental services. By submitting the request online, the dentist will receive a benefit estimate by the insurer for most procedures. Add the fact that many patients are unhappy when they receive EOB stating that they owe a payment amount to the dentist. Providing an estimated cost at the time the patient is in the office will not create a collection problem. Although, there might be a difference in the actual payment depending upon considering factors like frequency limits, deductibles, maximums, and other real-time conditions. 

When patients visit a dentist who accepts a PPO plan, an eminent portion of the discounted fees paid by the insurer, and they are responsible for the balance. Usually, the distribution of the discounted payment as per the treatment is low for the patients in most of the PPO dental plan. To maximize and make the most out of the PPO plan, the front office needs to be familiar with the following like what are the limits of the patient’s benefit, is this plan cover the endodontic services, is there any benefit left? In this case, how much? These prerequisites not only maximize the likelihood of collecting the full fee for the rendered services as well as have the total maximum benefit. 

Participating in any dental plan is entirely a business decision that each practitioner must take depending upon the market they practice to sustain a healthy financial practice with the best care for the patients.