To Participate or Not to Participate, That is The Question.

by  Christine Taxin
October 9th, 2014

Insurance!  Can it be profitable or a big loser?

Participating with insurance can initially bring down your revenue as you cut your fees per procedure. It is important to remember that your overhead will not decrease along with the fees. The question is can you make up the revenue by increasing the volume from PPO patients?

These are just some of the questions you need to ask yourself and thoroughly analyze the answers.

Evaluation of all your contracts

  1. Read your contracts before you sign
  2. Know how long the contract is for
  3. How often do they increase fee’s
  4. How do they set their fees and is it by zip code
  5. What % of the average charge per procedure code in your area does the insurance set it's reimbursement at?  (40%-95 %?)
  6. What zip code and % is your fee’s set in?
  7. If you want to drop contract how long do you have to give patients notice and keep treating them at insurance fees?
  8. How do you notify company?
  9. How do you notify your patients, of changes?


How to set your fees so that you are current?

  1. Know what the fee scale is in your zip code?
  2. What % are you now & how to move them up to be where you want to be?
  3. Fees should not be more than 25% lower when you are accepting insurance?


What insurance plans are acceptable for your practice? This can vary greatly depending upon your overhead. Size of office and staff. Area that you are located and the most important employers in your area. Here are just some types of insurance to consider

  1. Union plans
  2. HMO
  3. PPO
  4. Private indemnity plans
  5. Are they following risk assessment protocol?


Training team on dialog with insurance companies is important to make sure that you are getting the maximum benefits for your patients and you.

  1. These are just some of the conversations to have with companies you work with.
  2. Go over all the plans electronic information and how to use it to benefit patients and office.
  3. Set up your computer program to do as much electronic gathering of information on insurance plans as possible.
  4. Understand the insurance companies are not working against you; you have to understand the different policies with each company.
  5. Understand what limitations each plan has before you provide treatment.

Once this information is gathered it is important to have a dialog with your patients to review what you have learned.

  1. Prepare different conversations for different types of insurance
  2. Know what limitations exist for plan
  3. Knowledge of treatment and understanding what patients health issues are if work is not completed
  4. Have a Care Credit pre approval waiting to go over with patient as option to pay balance before you begin treatment planning.
  5. Have a set financial policy in place so everyone is treated equal in office.
  6. Have information on what type of treatment is needed and why.
  7. If there is a medical issue asks permission to contact their medical provider to work together on treatment.
  8. Have patient sign consent forms for accepted treatment and any treatment not accepted.

What about medical insurance?

  2. Another reason to make sure your fee’s are at the correct %
  3. Being able to bill multiple plans

How much do you write off on each plan per month?


Do you bill secondary dental insurance for your patients?



When can you use medical codes?

  1. Trauma
  2. Pedo in hospital
  3. TMJ
  4. Sleep Apnea
  5. When the dental treatment is caused or complicated by medical problems.



What types of insurances does your practice accept?



Private Insurance




What treatment codes do you bill for a cleaning?

To Participate or Not to Participate, That is The Question.. (2014, October 9). Find-A-Code Articles. Retrieved from

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