Dental insurance reimbursements haven't kept pace with inflation for decades. Meanwhile, your costs keep rising. Here's how to navigate the reimbursement landscape and maintain profitability.
The Reimbursement Reality
The math is stark:
- Annual maximum benefits have barely changed since the 1970s ($1,000-1,500)
- Adjusted for inflation, that $1,500 maximum is worth about $300 in 1970 dollars
- PPO fee schedules often increase 0-2% annually while costs rise 3-5%
- Administrative burden increases with prior authorizations and claim denials
PPO Strategies
Analyze Your Payor Mix
Know exactly what each plan pays and costs you:
- Calculate effective hourly rate by procedure and plan
- Identify plans where you're losing money
- Track write-offs as a percentage of production
Strategic Participation
Not all PPOs are created equal:
| Plan Type | Typical Fee Schedule | Strategy |
|---|---|---|
| Premium PPO | 80-90% of UCR | Stay in-network |
| Standard PPO | 65-80% of UCR | Evaluate case-by-case |
| Discount PPO | 50-65% of UCR | Consider dropping |
| DHMOs | Capitation | Usually not profitable |
Negotiating Better Fees
Yes, you can negotiate with PPOs:
- Document your value (reviews, quality metrics, patient satisfaction)
- Know your leverage (are you the only provider in your area?)
- Request fee schedule review in writing
- Be prepared to walk away
Growing Fee-for-Service Revenue
Strategies to increase FFS patients:
Attract Cash-Pay Patients
- Market to self-employed and gig economy workers
- Target retirees who've aged out of employer plans
- Emphasize quality and experience over price
Convert Insurance Patients
- Present insurance as a discount, not a decision-maker
- Discuss treatment benefits separate from insurance coverage
- Offer financing for out-of-pocket costs
In-House Membership Plans
Membership plans let you capture uninsured patients profitably:
Typical Structure
- Monthly fee: $25-40/month or $300-400 annually
- Includes: 2 cleanings, 2 exams, X-rays
- Discount: 15-20% off all other treatment
Benefits for Your Practice
- Predictable revenue: Monthly recurring income
- No insurance hassle: No claims, no denials, no write-offs
- Higher case acceptance: Patients use what they've paid for
- Patient loyalty: Membership creates commitment
Coding Optimization
Ensure you're coding correctly to maximize legitimate reimbursement:
Common Missed Opportunities
- D1110 vs D4910: Periodontal maintenance vs prophylaxis
- D4346: Scaling in presence of generalized moderate or severe gingival inflammation
- D0180: Comprehensive periodontal evaluation
- D0411: HPV screening
Documentation Requirements
Proper documentation supports proper coding:
- Perio charting for periodontal codes
- Detailed narratives for complex procedures
- Before/after photos for major treatment
- Diagnostic notes supporting medical necessity
The Bottom Line
You can't control insurance reimbursement trends, but you can control your response. Analyze your payor mix, be strategic about participation, grow fee-for-service revenue, and optimize your coding. The practices that thrive despite reimbursement pressure are those that diversify their revenue streams.
