Dentistry faces increasing standards for infection control following the COVID-19 pandemic. To limit transmission, the American Dental Association (ADA) has issued interim recommendations aligning with those from the Centers for Disease Control for infection control and the use of personal protective equipment. Under these circumstances, dental offices may see the need to readjust their fee schedules. The ADA anticipates that the cost of care will substantially increase for dental procedures.
If you are a participating provider with one or more dental benefit plans, you may need to negotiate your fee increases. This negotiation should be done individually, between only you and your plan, and not with or on behalf of other dentists. Before you enter negotiations with a payer, prepare your talking points and do your homework.
YOUR STRENGTHS: DO YOU HAVE ADVANTAGES IN TERMS OF ACCESS?
- Number of dentists in your locality
- Wait times for available appointments, impacting the patients covered under the plan
- Influx of new patients covered under the plan
YOUR NUMBERS: WHAT DATA DO YOU NEED TO NEGOTIATE EFFECTIVELY?
Know which procedure codes generate the highest total revenue for your practice, including:
- Frequency with which each procedure is reported
- Current allowed amount (i.e., your current discounted fee)
- Extent of these procedure codes’ contribution to your overall practice revenue
YOUR DESIRED FEE FOR EACH PROCEDURE CODE
- Extent of preventive services that your office provides
- Costs associated with operating your business
- Patient satisfaction rates (most recent available)
- Date when your fees were last revised
EFFICIENCIES YOU OFFER: WHICH OF YOUR BUSINESS PRACTICES ARE FAVORABLE TO THE PAYER?
- Electronic claims submission
- Use of online portals to verify eligibility and benefits
- EFT enabled for receipt of claim payments
REVIEW OF THE ADA’S DENTAL FEES
The ADA cannot quote fees for dental procedures and is forbidden by federal law to set or recommend fees. The Council on Dental Practice elected to discontinue the Survey of Dental Fees in 2023 and it has been removed for download, due to a change in law eliminating safe harbor disclosure. Posting such information, therefore, is now legally problematic.
- Use all of the above the information you have gathered to tell your story.
- Identify the payer’s provider representative assigned to your region who you can contact to begin to make your case. This may be someone known to your business staff, typically with the title of “provider relations manager.”
- Begin with email introductions. If comfortable, request a phone call or continue making your case in writing.
- Always be respectful. Let the provider relations representative know that you value the patients garnered from being a network dentist.
- Be patient and don’t give up! The first offer you receive may not be the best offer.
- Request information on whether the carrier leases their network and whether the revised fees will apply to any networks you have been leased into.
- After you succeed, make sure you have copies of all signed documents.
- Check the next Explanation of Benefits statements to ensure that the fee changes are appropriately reflected.
- Remember to re-negotiate periodically.
Good practice is to review your contracted fee schedules annually. Additionally, remember that it is very important to report your full fee on the claim form. Several payers set fees based on market rates. Payers may use the charges you submit to determine maximum-allowable fees. The fee schedules are typically part of the participating-provider agreement—a legal contract between the dentist and the third-party payer.
Other clauses in the contract along with documents referenced in the contract (i.e. the provider’s office reference manual) may impact the final payment from the third-party payer. For example, details about a policy that bundles the fee for a core buildup with the fee for the crown are in the provider’s office reference manual along with details on other processing policies. Importantly, review these documents carefully before trying to project revenues and negotiating fees with the payer.
Additional information on contracts and processing policies, along with valuable, educational ready-to-use resources on innovative dental insurance solutions, are available at ADA.org/dentalinsurance.