Introduction: You Can’t Build a Profitable Practice on a Weak Foundation

Imagine trying to build a house without first pouring the foundation. You wouldn’t do it. So why do so many dentists rush into PPO fee negotiations without doing the groundwork?

If you’ve ever submitted a fee increase request and got nowhere—or worse, were told you’re “being paid competitively”—chances are you skipped a critical first step: building your insurance profile.

Just like launching a product, expanding a business, or investing in real estate, preparation is everything. Before you even think about picking up the phone or drafting a negotiation letter, it’s time to step back and gather the right intel that sets you up for success.

Step 1: Evaluate Your Office Fee Schedule

Your office UCR (Usual, Customary, and Reasonable) fees are your baseline for all PPO negotiations. If your UCRs are outdated or too low, it’s impossible to negotiate up—because no payer will reimburse more than your standard fee.

Action Steps:

• Compare your current fees to the 70th–90th percentile in your zip code using tools like FAIR Health, ADA surveys, or services like Veritas Dental Resources.

• Increase any low-performing fees—especially in high-traffic areas like D2740 (crown), D2393 (posterior composite), D4341 (SRP), and D1110 (prophy).

Tip: Don’t round everything to zeros or fives. Randomized pricing (e.g., $1,116 instead of $1,100) appears more customized and less arbitrary.

Step 2: Identify Your Top 23 Procedures by Production

If you're not making your most commonly billed procedures a priority in negotiations, you’re leaving money on the table.

Run a production report over the last 12 months and isolate the:

• Most frequently billed codes

• Highest producing codes

This gives you leverage to say: “These 35 codes make up 85% of my production. We must focus fee adjustments here.”

Tip: Pay special attention to hygiene procedures (D1110, D4910), basic restorative (D2331, D2392), and major work (crowns, implants, endo).

Step 3: Assess Practice Capacity

Negotiating without understanding your capacity can backfire.

• Are you booked out 6+ weeks in advance? You may have leverage to drop your lowest paying PPO and reallocate that chair time to higher-paying patients.

• Struggling to fill your schedule? It may be wise to join a new PPO (temporarily) to increase patient flow while building your marketing engine.

Tip: Use chair utilization reports and hygiene reappointment metrics to assess true capacity before making any participation decisions.

Step 4: Audit Umbrella Networks and Leasing Arrangements

Many dentists are unaware they are participating with multiple PPOs through umbrella or leased networks (e.g., Zelis, Connection Dental, DenteMax, Maverest). These arrangements often yield lower reimbursements than direct contracts.

Action Steps:

• Request a current participation list from all umbrella networks.

• Cross-reference with your EOBs to identify who is paying through leased access.

• If the umbrella arrangement pays significantly lower, opt out of the lease and negotiate directly (if possible).

Tip: Use a color-coded spreadsheet to map all direct and indirect PPO relationships so you know who you’re really dealing with.

Step 5: Clarify Who You’re Contracted With (Directly vs. Indirectly)

It’s impossible to negotiate if you don’t know who holds your actual contract. Many providers assume they’re in-network with Delta Dental or Aetna directly—when in reality, they’re leasing access through a third-party network.

Ask these questions:

• Who do I have direct agreements with?

• Which PPOs am I contracted through an umbrella network?

• Which PPOs reprice claims based on another plan’s fee schedule?

Tip: Contact each payer to verify your contracting status or work with a PPO analytics vendor to map it out for you.

Step 6: Analyze PPO Contribution by Revenue

Not all PPOs are created equal. Before you approach negotiations, determine:

• Which PPOs generate the most revenue?

• Which ones generate the most patients?

• Which ones result in the lowest collections per visit?

This will help you prioritize which plans to negotiate first, and which may be candidates for termination if fees don’t improve.

Step 7: Prepare Your Talking Points and Documentation

Fee negotiations aren’t about “asking for more.” They’re about presenting a data-driven case.

Start building a negotiation packet that includes:

• Updated UCR fee schedule

• Top 35 production codes

• Production and capacity metrics

• Direct vs. indirect contracting map

• Examples of recent EOBs showing low reimbursements

Tip: Frame your negotiation as a request to remain competitive and continue delivering quality care—not as a demand.

Final Thought: A Strong Foundation Leads to Strong Negotiations

Most dentists want better PPO reimbursements—but few are willing to lay the groundwork to make it happen.

By building a strong insurance profile—evaluating your fees, capacity, production trends, and contracting structure—you transform negotiation from a wishful shot in the dark into a strategic, data-backed business decision.

It’s not just about getting more. It’s about building leverage before you even ask.

Benjamin Tuinei

Founder - Veritas Dental Resources, LLC
Phone: 888-808-4513

Services:
PPO Fee Negotiators | PPO Fee Negotiating | Insurance Fee Negotiating
Insurance Credentialing | Insurance Verifications

Websites:
www.VeritasDentalResources.com | www.VerusDental.com