Is being unscrupulous the only way to make a PPO practice profitable?

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10/17/16

11/14/04

I have a 20 year old general practice and have had a balance of PPO and FFS patients most of that time. Over the last few years, many of our FFS patients have converted to PPO; many FFS patients have left our area; some of our PPF and FFS patients have changed to HMOs.

So, now my practice is essentially all PPO patients. I have done quite a bit of reading, asking advice from dentists in the area, etc. looking for ways to make my situation more profitable.

Unfortunately it seems that the main tactic I have come across used by dentists I have read or spoken to is to 'game the system'. A few months ago, I read an article touted by Invisalign titled something like 'Make Invisalign profitable in a PPO practice'. I read the article and did see some efficiency tips (scanning vs. impressions, etc.) but I still didn't see how to be profitable considering the low PPO ortho benefit vs. the high Invisalign lab fee.

I called the author of the article to ask what else he does for profitablility with Invisalign. He stated that with PPO Invisalign patients, he tacks on an 'Invisalign Upgrade Fee' to the patient portion. This fee is variable in order to bring the total fee closer to his UCR fee. He does not bill this to the PPO, just to the patient. He also said that if the patient balks at the upgrade fee, he 'negotiates' it down until the patient stops complaining.

I also spoke to a local dentist who recommended that I charge a 'CEREC Upgrade One Day Crown Fee' over and above the PPO D2740 fee. I'm pretty sure this is what PacificDental Services does with their HMO patients.

I understand that we should charge/bill for every procedure that we legitimately perform, collect patient portions at time of service, stay current on our claims, try to maximize treatment per visit to decrease overhead, etc.

My question is, how common are these (IMHO) fraudulent practices being done to gouge PPO patients? Am I the only one not doing it? When I purchased the practice 20 years ago, we had HMO patients also. I got rid of them ASAP because I realized that being profitable was next to impossible without gaming the system. Is that the way it's gotten with PPOs now?

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Brad Location: Columbus, Ohio:

The answer is no. You don't have to be unscrupulous or dishonest in any way.But you do have to be selective in the plans you take. You have to be efficient, but not sloppy. You have to report every single thing you, including the items you might not have billed out before. Examples are study models, surgical vs routine extractions, sectioning a bridge...that sort of thing. Just report honestly exactly what you do.Do multiple procedures at the same appoint, IF indicated.Delegate what you can.

Sure, it can be done. You just have to work harder and smarter.

barstoolpigeons:

Speaking with my friends that work in corp mills, they use "cosmetic upgrade" fees to tack on $100 to crowns, etc. I would have never thought of such a thing, but apparently that's how the corp's do it to make more money. It's a (very) gray area. IMO, It would only be a problem when the patient calls their insurance to complain about having to pay extra upgrade fees (which will happen). Then shit might hit the fan.I just saw that I'm making a denture for $970 for a dentemax patient. I charge $1800 because I decided in school that because the faculty were such assclowns and made everything difficult, that I hated dentures and if I did them I was going to be compensated more than enough. Yet here I am, making a denture at about half my fee. It's getting hard out here...

michultra:

I'm sure I can be corrected, but usually those upgrade fees are for HMO patients, which you can do that on many of their plans. I think Pacific calls it "blue block" upgrade for emax. I don't think you can do this stuff for PPO plans though because contract states you can not. Its kind of interesting that the last decade has had General Dentists needing to learn to do many specialty procedures to be profitable. However, now the fees are getting so low it doesn't make sense for them to do them anymore. ie Invisalign upgrades. If they are doing the upgrades on PPO's, its just a matter of time until they get caught and penalized. A doctor or patient will report them for sure.

Thomasaurus Location: Corn Belt:

Just have to do what the ins plan will pay for. I don't do ortho so I don't know if Invisalign and ortho codes are the same?I certainly wouldn't put my money on the line for a patient to get upgraded tx if there was a chance I would have to write it off. They get what there plan says, I'm with the others on the idea that a lot of these upgrade fees put us at risk. The eob's are also very specific about additional charges.

OM JMiller Location: Glendale, Arizona

There are a lot of ways to make a PPO practice profitable without resorting to those types of practices.As Brad mentioned above, evaluate the plans that you do accept. Figure out your margins for your procedures that you are doing, and then analyze the fee schedules against your margins. If the fee is too low, get off of a few plans. Also, figure out what ins cos in your area have out of network benefits. The ones that do pay OON you can drop without a huge change to the patient's copayments.

Another way would be to add to your service mix if you feel comfortable doing so. Implant and sleep dentistry have been highly profitable for a lot of dentists on these boards. I'm sure they can tell you how to begin.Yet another way would be to start billing procedures to medical as well. Exams, x-rays, extractions, implants, bone grafts, perio surgery, appliances, and anything involving trauma can be billed to medical before billing it to dental. Our office and dentists that I talk to have added $6-$10K a month just by adding medical billing to their practice.So there are definitely many ways to become more profitable without having to "game the system".

pEru Vn: Location: CA

it is supposed to be a trade off.....reduced price for increased volume of patients.....but if every doc is in net, tough to get the volume of patients so you turn to increase volume per patient. thats how you do it....and unscrupulous in dentistry is in the eye of the beholder...mostly.

AZCrazy:

Insurance is a loser's game. There is a huge industry standing directly between you and your patients, which provides exactly zero service to the patients, but has a voracious greed and will beat both you and the patient down and take all the money for themselves if they can. They sell themselves to the politicians as the solution to the health care cost problem, without anyone standing up and screaming that we didn't have a 'healthcare crisis' until insurance companies got into the mix.

Dentistry is teetering on the brink of falling down the same hole the physicians all fell into a generation ago. Wouldn't want to be them now.

demteethies Member Since: 03/04/06 Location: Missouri

No, I think if you legally delegate everything you can, charge everything you can, make smart choices about your labs, materials, and work flow you can make it.

But there are procedures that probably are unprofitable if you aren't fast at them, like dentures.You need to find a consistent budget lab, the least expensive supply dealer, and the least expensive clinically acceptable supplies within that dealer.

Timmy G: Member Since: 04/14/02 Location: Raytown, MO

This is only half correct. You don't need or want a "budget" lab but you do have to find a lab that offers a reasonable price with good quality. Remakes are expensive. Quality does matter. No you cannot use a "premium" lab but a crap one will cost you more money.You do have to watch your supply dealers but hell who doesn't or at least who shouldn't. Again, remakes and redo's matter. Least clinically acceptable supplies. Hell no. Most expensive--no? But certainly not the least expensive. What is required is predictability in procedures, You are right--If there are procedures that eat up the clock then those should be referred out. But I would say again, it ought to be that way for most of us, anyway. Delegation of some things along with know what procedures are predictable and can be done efficiently is the key. There isn't time to mess with veneer cases, complex rehabs and the like. That's where you lose your ass.

WTP Member Since: 01/02/04 Location: Plainfield, IL

Everything Timmy said. PPO practices are really for the treatment of decay and infection and restoring with nice esthetic restorations that satisfy 80% of the population. Perhaps this may mean doing single shade composites and you can't spend 1.5 hours for a chairside resin veneer for $140. Large complex rehabs and patients who desire $300+ lab fee crowns are not really your market. Large complex cases can be done but IMO should really just be sent out to your FFS friends while your schedule is filled with the easy and predictable. Notice I didn't say the unscrupulous or sloppy or rushed.

pietrodds Member Since: 11/12/06 Location: PA

I know plenty of PPO docs doing ~32 hours/ week making 300-400K a year as an owner. You have to be efficient and work hard but it can be done without compromising your ethics. Most of the FFS practices I have worked in were run exceptionally inefficiently and I would find myself bored to tears with the patient flow. As another said, it is very hard to do extensive comprehensive rehabilitation in a PPO practice but the longer I do dentistry the less interested in those kind of high risk cases I get so PPO works for me.

WTP Member Since: 01/02/04 Location: Plainfield, IL

God bless the FFS docs with the training to manage complex rehabilitation patients. Also bless the specialists we rely on as well. It's the doctor that tries to do these cases at a low fee that creates the stereotype that PPO dentistry is bad. No, it's the doctors trying to pull off something on the cheap, or doing something rushed, or not investing in the training that is worthy of that reputation. But we all know that this happens in the FFS environment as well.

WTP Member Since: 01/02/04 Location: Plainfield, IL

Your MD takes your PPO insurance. Is he/she unscrupulous?

IEDMD: WTP, I'm confused by your question about my MD taking my PPO. I'm not saying that taking a PPO makes one unscrupulous, but if there was a 'exam chair paper cover upgrade fee'?...

Timmy G: Member Since: 04/14/02 Location: Raytown, MO

Well, take a look. There is the $25 for two aspirin fee. There is the $125 charge for the dispo suture kit of a throw away scissors and a few inches of gut nylon on a needle. Just to name a few. Have a procedure done sometime in a hospital or clinic--the line item charges they make, make us all look like slackers.

Janesaid2me;Member Since: 03/12/14 Location: New Jersey

Efficiency and quantity are key. No reason to be fraudulent. Bill exactly what you do. Make sure your office is collecting effectively. Co-pays and patient oops should be done before service. Hard for me to relate to 20yr old ffs practice as that is a unicorn in my area nowadays. Ppo is all I know.