Dental Unscripted | Getting into Ownership and Practice Management Insights

welcome to dental unscripted

for Mike Dinsio and Paula Quinn

break down the practice ownership journey

one episode at a time

starting up

buying and running a successful dental practice

hey hey guys

welcome back to another episode of Dental Unscripted

my name is Michael Dencio

and today we have uh

all next level people on the horn today

of course always Paula Quinn

the coast the program

what's up Paula

how you doing today I'm good

thank you um

Stefani is our billing and credentialing lead

and front office coach and all things front office

we have her on the on the

the pod today and we are discussing something that

if I had a dollar

every time someone asked me about this topic

I would be a very rich rich man

and it's all about should I drop my insurance

do we believe in being in network

or should we uh

get out mass exodus

there's some pockets in the country

where this is happening um

and I and it's a very good topic because um

it it depends

it depends on a lot of different things

and so

we're gonna break down this topic the best we can

and a very short period of time

um with

with that being said uh

Little Housekeeping please like

subscribe all the things

it does help us guys

it helps us rank it helps get the word out

we don't make money doing this um

and it's fun just

chatting about dental things and uh

that's what we're really here for

is for you guys and for uh

educating you guys all and being better owners

running practices successfully and all the things

so thanks again for listening and uh

please support us anyway you can

um Paula

when I say negotiate or terminate

what do you say where

where where does your head go

with the conversations that we have with our clients

and how many times you get this question

it's like um

where do you go with it where do you go with this topic

gosh that is a very loaded question

I'm gonna sound like you know

like I'm trying to skirt the question

but I think that you know

if if you're a startup and you're

you know starting from scratch

and you're trying to get new patients

and you want a ton of exposure etcetera

I mean you're gonna have to

you're gonna have to tolerate it for a while

um if you're established

and things aren't going the way you want

from a a fee schedule and insurance reimbursement

and you feel it's driving your practice

then it might be time to start terminating

I mean there is a method to the madness

and I'm sure you know

we'll get to that

when we're talking through things with Stephanie

but you know

you wanna be careful how you do it

I don't think a mass exodus is the right way

um

but do I get it all the time 100%

when do I negotiate do I take this insurance

should I be V for service

do I drop Delta you know

so I think we hear it all of the time

luckily we have the

the expert here that uh

knows the answers to those questions um

because it is and

I think it's just gonna get more and more talked about

as as things don't change in the insurance world so

well well well

so funny I'm gonna ask you here like

when is the best time to negotiate

before we go to that I

I am thinking about what Paula just said

and I always say like fill up first

like if you're not full

what are we even talking about

that's always where I go right

like we talk about our startups all the time

and you know

they just hate Delta and all the insurances

and they don't want 50 dollar cleanings

whatever it is and I get it

I totally get it but if you have

if you're just literally sitting there doing nothing

I'd rather have $50 for something

and you know if you're not full um I

I don't know how you don't take insurance

that's where my brain goes

the funny thing though

is doctors go through these cycles

so they get full and then they add team

add ops add days

and they just change their capacity again

so like before you go

to capacity changing your capacity

you can start having the conversation cut

cut insurances but if you change the entire metric

then you gotta fill up again

so it's like we always talk about our startups

starting with three days and they always

usually start with three operators and a skeleton crew

if you fill up three Ops that's a good point

in three days three Ops and you're jam packed

okay do we drop insurance or do we add UPS

do we drop insurance or do we add days

do like

if you change your capacity

it starts becoming a different conversation right

so let's just say hey

we are a a scenario

Stephanie is like okay

I'm a startup or I'm a practice owner

and I've been in business for two years

and I'm I'm on the verge

let's just say I'm

I'm thinking about expanding capacity

or maybe cutting or renegotiating

so can you renegotiate your fees

can it even everybody tells you it's no

it doesn't happen there's not really a negotiation

I think there is oh I

I feel like it definitely is all I hear haha

OK so by that response

it's clearly it is the case

when do you do that

so that's probably first step is maybe renegotiate

yeah I think

a few things that you have to take into consideration

is how long have I been in network right

how long have I been participating in these contracts

when we're even doing the initial credentialing process

you know

some allow it to entertain it on a yearly basis

some don't even want to talk to you for two years um

you know but you also have to assess that hey

are my getting increases willingly

so sometimes

we get inflationary increases on a year to year basis

Delta's pretty known for inflationary

you know

the state of Washington has now changed their format

that is provider performance driven

you know it really

I feel when I get providers like

I think it's time to negotiate

it's because their costs are increasing

so whether it's supplies it's staffing

that's really when they want to start negotiating

because they're like hey

my labor and my supplies are rising

but the insurance is not keeping pace

but I but I do say learning um

and this is you know

I hear Stephanie say this all the time

and this is like a different podcast topic

but I do hear all the time it's

it's learn to utilize your codes

and what you're allowed to charge for

and not allowed to charge for

with patients because sometimes

you can charge your UCR with different with

they don't meet limitations

and frequencies and things like that

so I think if you are really smart with uh

being up on that stuff and learning that stuff

you can get a lot more out of procedures than just

I have to I have to just take this on

the chin we

we watch practices give away stuff all the time

I mean PA's are given away

build UPS are given away

because we forgot to put it on the treatment plan

there's so many things that we give away

and we're sitting here and we want to cut insurance

and risk risk not

you know losing patients when

if we but yet

we won't tell them about that build up

we forgot to put on the treatment plan

you know what I mean it's like such an extreme it's

it's kind of like the marketing we did

where it's new patients

versus just keeping the ones we have in the office

you know it

there's so many things that go into it um

that it's crazy um

and people here think there's one answer

and there's not you're right

like the

usually when Paul and I have this conversation about

is it time or should we do it

it's kind of funny because like sometimes

and Stephanie you've seen this a lot too

where their UCR's are actually lower

than some of the insurance companies fees

and so it's like it's like

what are we doing here like

you're not billing for things

like Paula just said

your existing fees are lower than insurance or worse

Michael they have them in there and they're not

that's not what they're submitting

yeah

they're not even prepared to have that conversation

right like

we've been billing what you say

we can charge there is no room for negotiations

when I'm billing you what you're paying me

what leg do I have to stand on

well explain that a little bit though

because that I I

I know what you're saying

say that a little slower yeah yeah

so in any dental practice right

we should always be building our cash fee one

it's fair what we do to one insurance

we do to all the insurance

so we're building the same fee

for all of the insurance companies

um

and so what we need Dennis to do is to raise their fees

to hold insurance companies more accountable

so we all have room for negotiations

where I can come to the table saying

we are more than 60% apart

and we've been this way for X amount of years

it's time that we either negotiate

or I'm gonna have to find another avenue

on how I wanna participate

whether it's continuing a contract

being a fee for service or

you know there's other plans that we can optimize

different networks for a higher reimbursement

and you lose out so what you're saying

and I'll say it in a different way

is if we're not telling the insurance companies

that our fees are so much higher

then we don't have as much leverage to tell them

that this is this is a bullshit fee right

if you just build what they told you to build

then there's no gap essentially

okay I

I uh

there are some softwares that don't let you do that

though aren't there

or or or

or no

I think the problem is uh

dental offices don't know how to utilize their software

you know whether it's an incorrect claim format

or they just are building

you know have the wrong fee attached to the provider

I think that's a user issue

and not so much a software issue

that makes sense so is there a time frame

like

if I just got into network with anthem six months ago

can I call them and ask them for a better uh

rate or uh

what what's the timeline here

on when we should actually consider doing this

and renegotiate you know

I think every year is ideal

some networks will entertain

like I stated negotiations

doesn't mean you necessarily get it

but they entertain it some are closed

you know um

especially because it's location based

or it's a federal funded type of network

those are just closed for negotiations

but your ideal Mark is every year

you should always be asking

I think also it sets that reminder of hey

it's this time of year we need to be reaching out

so if Signa comes back and says hey

you still need to be two years into your contract

before we'll have this conversation

it's on your radar for next year

I think it still allows the office to get organized

so we have a system moving forward to negotiate

but let's not forget you know

I had a I had a dentist reach out to me yesterday

and you know that you want to negotiate

so Stefani taught me this

you always have to be prepared to go out of network if

if you're really fighting for that fee

asking is one thing fighting for it is another

so if you're gonna pay a service um

it's fine I talked about this yesterday

you wanna that two to three year

three if you really wanna

you know get the most bang for your buck

2 you're probably gonna get some movement

it's it's when is the best time

and if you're gonna ask on a year

and you're just gonna pick up the phone and ask

that's a whole different strategy

than what a company is gonna do for you

there are possibilities that you're gonna

just gonna switch networks

you're going to choose to go out of network for a while

so when you take a stance

sometimes

you'll end up being out of network for 90 days

before you can do anything

so you you have to be careful about how you approach it

and how you strategize

and be willing to switch networks

or go completely out of network

you don't want to just have hazily like

you know you can ask

asking is one thing strategizing around it threatening

threatening is another yeah

and you know

that's really where when we are

you know we do this service

obviously at next level

when we have these conversations and we're like listen

you can either restructure your whole network

participation or we

we really hold these insurance companies accountable

and we start the termination process and

you know then

a retention specialist comes out of the woodwork

at an insurance company and they're like

wait wait wait wait

but they wouldn't entertain it six months ago

and now all of a sudden we threatened to leave

they were like we

what do we need to do to keep you here

well I mean that

and guys that's

that's any negotiation if you're not willing

if you're not willing to walk away

then you're not going to get the best deal

but you have to be prepared to do it but

but let's go back let's say I have an office

Stephanie when

instead of just saying every year

every two years what maybe

what's a what's a metric

my fee compared to the intern's fee

I heard you say something about 60

is that when I'm like holy crap

or if I'm at 50 when do I say

I think at that 60 Mark you know

a national average is 40 to 50%

anything above that you know

we even have conversations

is sometimes it just does not pencil

what are the pros and cons if we don't

you know

elect to move forward with this insurance company

are there out of network benefits right

we have those conversations

but anything over 60% you know

it's first

we put it right back into the insurance hands and say

this is insulting at this point right

wait wait

I want to make sure that the audience is understanding

what you two are talking about

so when you say a percentage of

first of all you're talking about a percentage of your

your fee for service fee or your UCR correct

right what office is considered a write off amount

right it would be that amount

that percentage and so

so uh

for for

for those out there you

you got a procedure it's $1,000

and the insurance company has you at 600 or less

that's the time to discuss that now

guys or ladies um

a lot of our offices or not our offices

a lot of offices out there

don't even have their UCR's updated to the market

so what are we so now this is a moving target for me

so are we assuming that the

that that you're working with next level

we get your fees

up to the 90th percentile of the market

and you're saying 60% of that

yeah because I would say when we

when we work whether it's an acquisition

or practice management in general

when we look at their fees

I would say they're usually in the 40 50

40 to 60% range not at the 90%

so if they're

if they haven't updated their fees or they don't

they have updated them

but they're just magically saying oh

let's update them if they don't know that true number

it's hard to know that gap between you

and however

if your fees are 60% and you've never negotiated

and you've been just fine with it

you probably still are 50% below what Delta's pay

or you know what somebody's paying you

because you've been fine with it all along

you've never done anything about it

so yes

the goal would be get your UCR's where they need to be

and if you've been solo for so long

and that gap is tiny

you may have to wait a little while to reap the rewards

it doesn't hurt

but to reap those rewards of that significant change

because you've you're

you're down at the bottom of the barrel already

that's interesting and offices believe that they can't

because then who do they hurt

is their cash paying patients

but there's always another avenue to offset higher fees

right whether it's an in house membership

so you don't I feel like we get providers that are like

no that's too aggressive right

and it's just that's not the case

there's ways to do it okay

so now now

oh go ahead Paula

no it's okay

no no

what were you gonna say I don't know where

I don't know where you're going

I was gonna change it just a little bit

but I wasn't going there so

let's flip the script and talk about lease

networks versus direct so you guys just mentioned like

re looking at the entire strategy

and approaching these insurance companies

so um

I get a lot of the questions about like um

you know what the pros and cons of

of lease versus direct

do you have a more do

do you guys look at how when you look at this

does it give you more leverage

is ultimately what I'm asking

um and is it part of the strategy of negotiating um

looking at least networks versus direct

yeah I think you have to look at everything right

it's not necessarily least networks pay more right

you'd be surprised that

some of these direct contracts can pay more

but you have to look at everything

before making a decision so a good due diligence you

you know credentialing is done at a network level

some insurance companies have their own network

and some do not have one

so they use what you're referring to

a lease or an umbrella network where it's one contract

a list of insurance payers that also accept it

um I think today's insurance company

believe it or not

they're getting a little bit smarter than we are

um you know

they'll give a sample size of their network

to these leasing companies

but they try to make it harder to get the full access

and to get full access you have to go direct

so you have to know what plans are

you know in your office

you have to know where the demand is

you don't want to isolate

you know some of Etna

and you now learn lose the commercial PPO right

we just we just talked about that

Paula in

in the marketing episode of understanding the companies

and the the insurance companies

and I

I wonder what that bridge is if I looked at an employer

and we'd have to know the employer's plans now

to be able to recognize that um

that that's

that's really really interesting

um yeah

they make it very archaic

these insurance companies

they're stuck back you know

so many years ago um

I think you know

on that you know

the we

we started out with out of network

you know do you go out of network

do you terminate or do you stay

and I think before we go there

I would ask you Stefani

you know there's a lot of mistakes officers make

but there's a mistake when um

they just decide to credential on their own

and start filling out contracts

I hate it I hate it

and there's also mistakes when they do decide

and we kind of mentioned it a little bit

when they decide to go out of network on their own

um and we talked a little bit about

if they negotiate on their own

what do you think you know

maybe a little bit maybe one or two

things in those three categories

does a company like Next Level bring for them

rather than do it DIY

because you know

we have chat GPT now oh yes yeah

everybody thinks that they can do it

I think one when selecting

you know

providers don't know any better

and I think also

some front offices are much more greener than others

um you know

you hear we have to make sure we accept Metlife

so what do they do

they get the application for Metlife and just go

rather than you know

I like to think of a house

there's multiple doors of a house right

is it best to go through the front door

or is there a side entrance that we can go

that's a little bit you know

more profitable a little bit

you know better paying

but they don't see the way

they're just you know

trained to go to that one house

so I think they see the need

and they just jump the gun and they do it

um I did that

I don't know if you remember I

you know I've been in dentistry like

my whole life but I remember yelling at you

I'm like why did you run off that person

so and I didn't have Stefani or anyone

so I called all the insurance companies

got all the applications

and went direct for my poor associate

who got the shittiest fees in all of America

and Paula had to hand write these applications

which makes me laugh

I was in misery and then guess what

when that associate left I had to do it again

um

and I should have filled out the top part at least

with the name of the practice and all the stuff

so I didn't have to keep doing that

I had to start from scratch again

so I 100% understand why somebody would do that

they don't like you said

they don't know they're just like

I need to be in network with everything

and you just start filling out applications

and you cut your nose off

despite your face and now you're stuck

and adding to that you know

with these acquisitions sometimes

we don't want to notify them that it's an acquisition

we want to let that tax ID be

we are going to be a shared space as a new entity

and look at what a new contract looks like

because again

the insurance companies know

you know most offices don't know any better

so they're like great

we'll give you the same fees

when new providers you know

whether they come provider kind of driven fee schedules

right carry over

and so they could have a better fee schedule

if they had a you know

established a new contract

rather than like an acquisition type of contract

that makes sense so it's like listen

I'm not let that contract stay in place

I don't want it I want my own contract

this is not gonna be an acquisition

so you have to look at it from every single angle

because

the insurance companies are not gonna be forthcoming

and telling you this information

right right

OK OK

so I I think we covered that at large

we do need to cover

just a little bit of the out of network conversation

cause this isn't a how to negotiate episode

so when

when you look at going out of network and terminating

that that can also be a big mistake as well

so are there tips and tricks ladies

on what to do

or how to approach this dropping of insurances

is there a playbook here and what do you guys suggest

yeah I think if you don't have a

a strong insurance verification

offices think we don't take insurance anymore

we don't we can do the bare minimum

when it comes to insurance verification even right

you know we're not looking for assignment of benefits

we're not looking at

at what amount are they going to pay

right out of network they pay one of two ways

my cash fees based on my cash fees

or they're allowed amounts

and I have to know the difference

they are not prepared in any capacity

and then we see AR they're like

yeah no

this claim never we never got paid on this claim

well it's because they paid the patient and we didn't

we weren't prepared ahead of time to

collect it from the patient

it is you know

even with offices that don't just go out of network

that still had to have that healthy mix right

it's not heavily PPO they still struggle with this

and you know

there's always a song and a dance up front

and I and I love my front office people

I do um

but you have to be hungry enough

to know where the errors are made

and make those corrections

so insurance verification

I think it's communication with these patients

you know

one of the biggest things when we terminate contracts

is patients get notified from the insurance company hey

letting you know

your provider is no longer in our network

and then everybody's hair is on fire

right Paul

that's a mass exodus right there

oh god

so so what would you do to get ahead of that then

cause that that is big

it's having these conversations with the patients right

whether you talk to them at their hygiene

and maybe Paula has some other

you know tips

but at that hygiene hey

this is going to look different in six months

I wanna let you know what you can prepare

the insurance company is gonna send you a letter

but don't worry you still have out of network benefits

your insurance we're still gonna accept it

it's just gonna look a little different

we will honor your treatment plans currently right

for 90 days it may look different

in 90 days but

I think communication is really big

with these patients

and preparing them so they're not like

I have to go find a new dentist

mm hmm

yeah and

and I think also Stephanie

make sure and and you

you may have said this I was like

intensely looking at you so I don't think you did

what happens if they don't have out of network benefits

you know it's

it's they

now we have to rely I believe

on our patient care how great our office is

how wonderful our dentist is

and it's not to say hey

you can't you don't have out of network benefits

we could lead them into our in office memberships right

and bring that home say listen

and you know

dental insurance is is typically inexpensive

to people who get it through their employer

so it's not a sorry

you're wasting $13 for the rest of the year

you know what I mean but we

if you love our practice and

you know you trust us

I think trust keeps the patient in the practice right

and this is what it looks like

and we're gonna help you the best we can

so we can continue to take care of you

take care of have this relationship absolutely

mm hmm

so I think out of network

the biggest things Michael

to repeat that is you know

number one where is the money gonna go

you know the assignment of benefits

um you have to know that

or else you know that you could go out of network

and the money could all be going to the patient

and if you're not on top of your ARs in the situation

you may never know

if you're not verifying that insurance

and someone doesn't have out of network benefits

you can't even see them so you have to be careful there

unless like Stefani said

we convert them to a fee for service

or in house membership program

they can use in our practice

so they can continue to stay

um so you just wanna

you just wanna be fully prepared before you do that

and I think there's a way to go out

and I think part of that is

looking at your current patient base

and finding out who do we drop first

who do we drop second we don't have to drop

we don't have to go out of network all at once

we can pick and choose based on reimbursement

amount of patients you know

the strategy will probably look different in each

in each office

because just because it's my major majority of patients

of my lowest paying fee schedule

I still may choose that first

you know so and

and like Stephanie said

having those conversations with the patients

before they get that letter from the insurance

because that's gonna push the panic button

and then

the front office is really not gonna know how to

handle that those phone calls

I should say and I think also it's

it's having your protocol

your financial policy in place right

um if you're not gonna take insurance

what type of liability are you still going to have

when it comes to the patient's insurance

is it the claim submission

is it you're gonna collect everything up front

because it's still a financial decision

that people weigh in when

you know selecting their treatment

so I think you have to so what Paul is saying is

you have to have all of these in place

and I do recommend Smalling

starting with a smaller network

right maybe that you don't have a lot of plans with

and get comfortable with that system and implementing

and the verbiage yeah

before you take on Delta yeah

that totally makes sense

and then I have one more thing to say

cause I know we're pretty much wrapping up

did you have any more questions

Michael on that or comments on that

no last bit

Stephanie said no um

I do want to remind dentist though

insurance is a piece of marketing

and there's a price to marketing

and if you're in the directory

and patients are automatically just calling

because they look up dentist near me

and they're saying do you take my insurance

you have to remember there's a price for all marketing

and if you're getting people because you take Delta

or Met Life or Guardian

you are gonna take a hit on that new patient account

yeah that

that that procedure

so you know

we're all we're all against insurance

but you know if I'm

if I'm an insurance driven patient

and Delta or Blue Cross

Blue Shield or Metlife or Guardian are my insurance

and you choose to go out of network

you might lose me and you may say oh

I don't want you anyway but you know

you may lose 100 of us and you have to decide

okay so I got a thousand dollars for a crown and not 15

I don't know do I wanna lose a thousand patients

you know so they're

you know they ask us all the time well

what's the damage and it's like gosh

I don't know what's your patient experience look like

what how does your team treat them

what's the waiting times

how is your treatment presentation

are you close to financially

or people always getting statements

because if they're already frustrated with you

even a little bit

that's gonna be the straw that broke the camel's back

if you if they absolutely love you

and you're spot on and the experiences of me

you know it might be worth

you know the full fee and they may not go anywhere

so I can't tell you the damage in your practice

uh huh it's

you know it's

it's team dependent really

so yeah

now I'm I'm glad you said that Paula

because it it really is

a strategy that needs to be thought through

from start to finish uh

from what is the participation levels

what insurance is what are the verbal skills

to what's our customer experience like and

and being real about all of that

before making the decision and

and that's why I said and I'll

I'll start the episode and end with it

if you fill up

you're prepared to to lose some because you're full

but if you change your

your capacity and now you need those patients

that's not a good time to do it

when you just hired someone

just added date but when you're packed and you're full

gosh I'm busy as hell

it would be okay if I lost 100 patients

that's the time to do it

so I think if you are considering this

you should probably reach out to us

we'll be happy to talk to you about it

and help you and work through it

but it's a big big topic

big topic uh

that's right well

thank you ladies for your time and uh

your expertise today it's a um

a good day at dental unscripted

having the next level crew on

and I I really appreciate both of you

so thanks so much alright

okay bye

we will talk next time bye

bye guys

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