Transitioning out of network with a dental benefit plan or from associate dentist to the new owner of a practice can be challenging enough as a single undertaking. Doing both successfully within a year requires a lot of planning and careful implementation to reassure patients and employees and minimize patient attrition.
Elias Almaz, DDS, successfully acquired a dental practice in 2022, but the planning began several years earlier. He shares that journey with CDA and his peers who are considering a similar transition.
A desire to reduce Delta Dental’s impact on practice operations
While working as an associate dentist at a private practice in and in the early stage of negotiating to purchase, Dr. Almaz was already looking at the patient base and knew something needed to change.
With Delta Dental patients comprising approximately 65% of the practice at that time, he was concerned that Delta’s policies and reimbursement would negatively affect practice operations after a transition.
Looking at the analytics before executing the purchase, Almaz identified the risk. “Given the already substantial difference between the practice owner’s Premier fees and the PPO fees that I was receiving, if Delta Dental were to make any changes to reduce reimbursements even further, I knew I’d be in major trouble because they are the majority of the patient base,” he reflected. “I wanted to find a way to balance the patient demographics and ensure that I could provide the appropriate treatment for my patients.”
Dr. Almaz and practice owner work together on exit strategy, hire consultant
Once he determined that moving forward with a Delta Dental PPO contract would not be sustainable as a new practice owner, Almaz began discussions with the selling dentist, who volunteered to assist with the plan exit process.
“We were very nervous because as the new dentist who’s coming in, I’m making all these changes, and the patients may worry about even more unsettling changes in the future,” Almaz said. “I could be their deciding factor to leave and start over somewhere else where they feel more secure.”
While not always necessary for a dental plan exit, Almaz and the practice owner opted to hire a consultant who could offer analysis and recommendations to mitigate patient attrition based on the unique circumstance of an upcoming transition in practice ownership.
Largely for that reason, Almaz and the practice owner wanted to offset the contract termination by at least three months, but because they started strategizing much earlier, they had closer to a nine-month lead time before notifying the first patients about upcoming changes. The lead time allowed for strong patient tracking and strategic adjustments to address patients’ concerns.
Almaz also credits the practice owner’s close involvement in the process.
“He actually wanted to ensure that the drop happened under his watch,” Almaz said. “He determined that if the patients experienced change during his ownership, the practice would be healthier and safer. When he brought me on board as an associate in 2017, he made clear he wanted to try and protect our flock with continuity of care. He’s had a very patient-first mentality throughout his career.”
The hygienists discussed the benefit plan changes with patients
The consultant recommended that the dentists have the necessary conversations about benefit changes with their Delta Dental patients, but they opted for a different approach.
“The hygienists are spending an hour with these patients every six months,” Almaz said. “They’re having a lot more conversations than we typically have during restorative appointments, so after we discussed it as a team, we all agreed to have the hygienists .”
The practice had two hygienists who are still with Almaz today; one has more than 20 years at the practice and the other over 10 years. “Both are loved by our patients,” Almaz added.
When patients had financial questions about benefit changes, the hygienists directed them to front-office employees who would go over the new payment structure with them, explaining that instead of leaving without paying a copay, Delta enrollees pay for treatment upfront and receive Delta reimbursement directly. Patients who were not on a regular recall schedule or who called the practice only when they were having problems learned about changes from the front-office employees, but the entire team was working from the same script.
“Staff would comfort the patient as much as possible,” Almaz said. “On day one, we started running the numbers for patients who were on the fence and needed to know what their out-of-pocket costs would be. They were able to determine what their six-month recalls would cost — to the dollar, essentially.’
Almaz had also been studying the explanations of benefits for the few out-of-network patients he saw before the practice terminated its contract with Delta Dental, which he says greatly helped him understand the process and how to anticipate the typical reimbursements for out-of-network treatment.
“I also learned that in many cases, Delta Dental is just managing employer-funded plans and that while some employers use Delta’s recommended formulas, other employers override them and set their own maximums,” Almaz said. “Still, we were very careful to not over-promise to our patients.”
He also says that his UCR fees are on average quite a bit lower than other dentists in his area, which makes less of a hurdle for patients who might otherwise think they need to go find an in-network dentist instead.
Close tracking provided ‘a good estimate of how many patients would stay’
The team tracked and graded their conversations with every single patient to try to determine whether the patient was “on board” with the coming changes, Almaz said, but there were still surprises.
“We’d think a conversation went well, but the patient wouldn’t make it through one recall cycle. Conversely, we talked with patients who’d indicated they’d be out the door the minute we made a change, and some of those patients are still here. But with this close tracking, we were able to get a good estimate of how many patients would stay.”
The consultant’s patient attrition metric is based on the number of patients who leave after the practice goes out of network with a plan.
Almaz estimates the practice’s patient attrition at about 25%.
Of the approximately 1,200 Delta patients the practice had prior to dropping Delta Dental, 257 left the practice. Almaz said it took almost two years to completely stop losing Delta patients. “I tracked the numbers every month to really understand when attrition was leveling out so I could start breathing,” he said.
Practice regained patients after they left through letter campaign
Almaz and his team diverged from the consultant’s advice in just one other way: They developed and implemented a plan to send letters to patients they learned had left the practice to see if they could regain some of them. Almaz called the effort a success and suggests other practices in this situation consider trying it.
“We wanted to allow these patients time to find and get established with a new dentist and feel good about their treatment, so we waited until about eight months to send those letters to every patient who fit that category,” he said. “Our letter stated that we hoped they’d found a good dental home, but that if at any point they were unsure, they were welcome to come by. We wouldn’t charge anything and only wanted to make sure the patient was in good hands.
“We did have patients who returned and indicated the letter came at the perfect time, that they were questioning the move, really liked us and wanted to come back.”
‘I have steady growth without needing to spend more’
Almaz’s practice does continue to bring on new Delta Dental patients despite being out of network with the plan.
“We have a retention rate of about 80% on that first call because my team is very good at explaining what it means to be out of network and what the patient can expect, so four out of five times, the patient will still book the first appointment and stay,” Almaz said. “Others, like new families who’ve moved here from the Bay Area and want to get established at a practice, tell us no problem because they are used to seeing dentists who are out of network.”
But the team still closely tracks the number of new patients and the patients who leave, and they continue to have regular check-ins on Delta Dental issues.
“In every meeting to this day, the team sits down together and asks, ‘Did anything new with Delta happen this time? Did we stub our toes in any situation?’ But we’re still at a net positive per month. Could I have more patients? Absolutely, but I have steady growth without needing to spend more.”
The practice focuses on internal marketing and relies on reviews and recommendations but has not spent more on external marketing. “People take advice from those they already know and trust,” Almaz said. “Someone you know saying, ‘you’re going to love my dentist,’ speaks way more than a paid ad.”
Going out of network with Delta Dental ‘has reduced a lot of stress’
When thinking back on the most difficult aspect of the two-part transition, Almaz cited the expense of buying a practice, including needed upgrades and replacement of equipment and second-guessing the practice location.
Uncertainty was another major worry. He called it “being in the dark with Delta Dental.” “And not knowing which patient is going to drop next was difficult,” he added. “That was eating me. It doesn’t feel good to lose patients ever, and I knew that some patients left because there’s attrition when a new dentist steps in, no matter what you do.”
But Almaz lights up when he speaks about the positive impacts and even the pleasant surprises of going out of network with Delta Dental.
“Going out of network with Delta Dental has reduced a lot of stress,” Almaz said. “We have fewer checks and payments to process and less to track with Eaglesoft, and that’s been nice.”
Almaz says the office continues to review outstanding claims to make sure they are processed correctly and patients are getting paid, but the overhead is considerably less than it would be if they were in network with the plan.
“I’m able to practice dentistry in a very clean and pure style, which is how I’ve always wanted to do it,” Almaz said. “I don’t want to have to play by somebody else’s rules, and now I have the freedom not to. I wanted to be a dentist to help people.”
“These changes have been good so far, and I hope I’m doing it the right way. Our patients have been very understanding of these changes, and I respect them because they took a leap of faith with me on this. I want to make sure that they still feel like they’re winning.”
More ahead in CDA’s series about members’ diverse practice models
Watch for the next article in CDA’s series about member-dentists who have pursued diverse practice models, approaches to working with dental plans and patient care financing options.
All articles will be available in CDA’s Dental Plan Action Center, where members can also learn about CDA’s legal and legislative victories for dental plan reform and find guidance and resources for working with dental benefit plans.
CDA’s series highlights individual member-dentists’ experiences as examples for other practices but reminds dentists that every practice is different and therefore every practice should review its own books and make its own decisions. This article does not constitute guidance from CDA’s dental benefit analysts.
CDA member resources on dental plan contracting and billing: