Important: Your analysis of all dental benefit plans you consider should be done unilaterally for your practice and not in coordination or consultation with other practice groups. Discussing or exchanging views on this with other practice groups can lead to serious legal problems because "joint action" among competing dentists can be viewed as unlawful.

Evaluating New Dental Benefit Plans

Use the information below to help you determine if engaging in a new dental plan contract aligns with the dental practice goals and business model.

Before you begin, obtain and review:

• The dental plan's proposed contract/provider agreement between you (the provider) and the plan.
• The proposed fee schedule from the plan (specific to your practice address /TIN/specialty.
• The dentist handbook, billing guide, and any applicable rules from the plan.
• The contract analysis completed by the ADA (link to CDA website for the ADA analysis information).
• Any other documents referenced in the proposed contract/participating provider agreement

When considering the choice to participate as a participating provider with a dental plan, be diligent in your research. Additional time spent at the outset to make sure you understand the new arrangement can save a great deal down the road. Consider the following factors in your decision:

Practice Model

1. What are your reasons for considering a contract with this plan? Some reasons may include:
   • The plan has contacted you to contract.
   • Existing patients of yours have asked you to go in-network.
   • A large employer in the area offers this plan to its employees. 
   • You need to increase your new patient volume.
   • You are losing patients because you are out of network.
2. Does a contract with this plan align with the practice model you have or want to have? Ask yourself:
   • What percentage of your practice is dental benefit plan­ driven?
   • What percentage of your practice is cash-based or pays the normal UCR?
   • Will a contract with this plan support the business model you want for your practice?
3. Will the new plan drive a significant portion of your total business to a lower fee? If so, how will this impact your total business?
4. What are the plan's limitations and exclusions? Research this thoroughly, and not only evaluate what is included, but also the frequency of exams, radiographs, prophylaxes, and replacement of restorations. Usually, you'll find this information within the dental plan's handbook or supporting materials.

Dental Practice Staffing, Scheduling and Capacity

1. Have you asked the plan For a list of employers in the area who provide this plan to their employees?
2. Have you researched the employers who offer this plan to see how many employees they have in your area and assessed the potential new patient influx to your practice? If not, you should consider:
   • Contact employers within a reasonable commute to your practice. Ask to speak to a representative in Human Resources who can tell you the dental benefit plan offered to employees.
   • Ask the dental benefit plan representative the statistics on the employers covered by the plan and how many employees/ potential patients are in your practice region.
   • Will a contract with this plan support the business model you want for your practice?
3. Based on what you learned from the process outlined above, do you have the capacity for more new patients potentially generated from this plan contract? Can you meet the access to core criteria (for routine and emergency care) outlined in the dental plan contract?
4. Do you have a highly trained front office billing coordinator who can manage the additional claim volume that will come from this plan contract?
5. Do you have the capability to submit electronic claims and to accept Electronic Fund Transfers (EFTs) from the dental benefit plan?
6. How many of your existing patients are enrolled in this plan?
7. Have you researched the employers who offer this plan to see how many employees they have in your area and assessed the potential new patient influx to your practice?
   • Pull 10 of the patient charts and look at the past 2 years' production from those 10 patients.
   • Determine how much the production will change by contracting with the plan based on the fee schedule the plan provided to you.
8. How many dental practices in your area already participate in this plan? Evaluate the supply and demand — are employees struggling to find a dentist in the area who accepts the plan?

Evaluating Existing Dental Benefit Plans

Use the guidance below to help you evaluate existing dental benefit plan contracts to ensure the contractual terms still align with the practice goals and business model.

Before you begin, obtain and review:

1. The plan's contract/agreement between you (the provider) and the plan.
2. The most recent fee schedule from the plan (specific to your practice address/ TIN/ specialty). Note: If your practice is moving, adding another location, and/or adding another provider, this will change the contract and potentially the fee schedule.
3. Your separate UCR Fee schedule for cash-paying patients. (See Fee schedule questions below).
4. The current dentist handbook from the plan and any applicable rules that apply to the plan's dentist network.

When reevaluating your current contract with a dental plan, be diligent in your research. Sometimes is necessary to make plan changes as contracts evolve over time. Consider the following factors in your evaluation process:

Fee Schedules

1. Do you have a separate UCR practice fee schedule for your cash­ paying patients? It is a wise practice to do your own separate UCR, separate from the fees the practice accepts as a part of the dental benefit plan contract.
2. Do you review the practice fee schedule annually and determine if your fees need to be increased to reflect CDT code changes or increased overhead costs lo the practice? A few sources in which to obtain fee data are: 1) The Fair Health Consumer Cost Lookup, for no-cost survey results of typical fees charged by providers by ZIP code or 2) The National Dental Advisory Service Fee Report Book, available annually for purchase.
3. Have you compared your UCR fee schedule to the dental benefit plan fee schedule in which you are contracted?
   • Run a report of your UCR fee schedule for the top 20 CDT codes in which your practice bills. Run the same report for the dental benefit plan fee schedule.
   • Develop a spreadsheet with a side-by-side comparison of each CDT code.
4. Do you bill the plan according to your practice's fees on the claim form to show the plan your UCR compared to the contracted fees?
5. The process to do this will vary by the dental management software and may require an upgrade of your software to accommodate this task. Reach out to your software vendor to ask how to bill your UCR on the claim form.
6. Do you track the difference between your UCR and the plan contracted fees for each patient with this dental benefit plan?
7. All dentists should submit their UCR when billing any dental plan (contracted or not) to ensure the dental plan's record and analyze the current UCR in the respective regions of California. By submitting only contracted fees to dental plans, the UCR data reported by providers understates the amount of fee discount you may have agreed to with the plan. Instead of knowing that discount, your claim for reimbursement will reflect a net discount of $0. It is these inaccuracies in claim submission that are contributing to the attempts at fee decreases and lack of increased reimbursement by the dental plans, as the plans aren't receiving the complete picture of the true UCR and the true discount. Additionally, by failing to submit your UCR and adjusting the patients' accounts upon receipt of payment, you are unable to correctly establish the cost of the dental plan contract to your practice.

Production and Collections

1. Do you know the percentage difference between your practice's UCR and the plan contracted fees? For example, do you know if your fees are 30%, 40%, 50% higher on average than the plan fees? Is the adjustment (write-off) of the contracted fees worth the benefits the contract brings to your practice? Benefits might include increased new patients, marketing, increased case acceptance.
2. Do you know what percentage of your total active patients have benefits with this dental benefit plan? Does this plan make up 20%, 30%, 40% of your overall active patient number?
3. Do you know how much production and collections you generated from services rendered to patients with this dental benefit plan in the past year?
4. If you lost all the active patients who have benefits with this plan, what would be the total collections loss to your practice? If you lost half of the active patients, what would be the total collections loss b your practice? Look at the prior year's collections to determine the potential loss to the practice. Determine if it is financially feasible to have patient attrition if you discontinue your contract with this plan. Plan for the worst-case scenario and make sure you have the financial stability to sustain the worst-case scenario while you build back up your patient volume in other ways.

Your Contract

1. How timely is the dental benefit plan reimbursement? Is the plan easy to work with or does it give you and your staff a tremendous headache and take up more staff time (compared to other plans or financial arrangements)?
2. What types of services/procedures have patients on this plan received in your practice? What services are covered or not covered? Are there a lot of exclusions in the contract which prevent patients from accepting treatment?
3. Does the plan offer electronic claim submissions and Electronic Fund Transfers to expedite payment to your practice?
4. Does the plan retroactively reduce fees or disallow claims based on a subsequent review of the procedures and billing?
5. Does the plan often deny certain items on claims compared to other dental benefit plans?
6. Is your competition accepting this plan? Will your existing patients on this plan have numerous dental practices to choose from if you discontinue your practice's participation? Evaluate the dental practices within 1-3 miles of your practice. In most parts of California, patients will not travel more than a few miles from home or work for services.
7. If fees are a factor in your reason to terminate the contract, inform the dental benefit plan that you would believe an increased reimbursement is necessary and proper. If you do not speak up, the dental benefit plan will likely not adjust its fee schedule. Send a letter and follow up with a phone call.
   • The department in which you negotiated your initial contract is the same department responsible for maintaining your contract. Go back to that department to inquire about the process to submit the updated fee proposal and request increases.
   • Refer to your contract and/or dentist's handbook to find the process to submit updated fees. The process and frequency will vary from plan to plan.
   • On the plan's website, look for keywords like "join", "enroll" etc. under the "provider" or "dentist" section. This should link to the Third Party Payer contracting departments where you can communicate your request to submit updated fees.

If you are still considering terminating the plan after this evaluation, please read: What You Need To Know About Dropping Dental Plan Contracts 

Additional Resources