We’ve posted extensively about the differences between direct PPO contracts and third party administrators (link to DT article here for more information: http://www.dentaltown.com/Images/Dentaltown/magimages/0614/DTJun14pg22.pdf ). In the past, direct contracts with a company would override third party administrators so the strategy has been to use direct contracts when the rates are higher and when using a third party admin, use it only when a higher paying direct contract was not available. We’ve started seeing cases where payments were starting to shift downward, especially when more than one shared network agreement was in place so we knew the trend would be where insurance companies would figure out how to start paying on the lower paying option.
We just got confirmation for the first time in writing with a company (that will remain unnamed) that a shared network agreement can take priority over a direct contract with them based on which fee schedules gives the best value to the member.
This is a huge game changer because it’s the first written confirmation we’ve had of what we knew would be coming – that you need to assume that your lowest paying fee schedule could begin dictating fees with other companies regardless of if you have a direct contract in place. We are not seeing this industry wide yet but assume it’s coming and start strategically planning.
If your staff is not watching EOBs continually and making sure that the fees paid are based on the contract you signed, chances are you are getting payments downgraded and not even realizing it. We see offices all the time that are just entering payments and not watching to be sure that fees are not getting downgraded. This is something dentists need to be making number one priority for whoever enters payments. The days of just entering payments without having a clear understanding of fee schedules, contracting and shared network agreements are over. Most companies have Opt Out options where you can play the game still to shift to higher paying options but you have to put those into place yourself for your benefit or assume the insurance companies will start to shift you downward to what’s best for their benefit.