Title: PPO Fee Discrimination – Is It Legal for Insurance Companies to Pay Your Neighbor More?

"Why does Dr. Smiles down the street get paid more than I do... for the same filling?"

If you’ve ever stumbled upon a patient's EOB that reveals a higher reimbursement for another dentist in town—don’t worry, you’re not alone. In fact, what you’ve found might be more than just frustrating—it could be ammunition. No, we’re not talking about dental espionage or stealth fee-foraging. We’re talking about a legitimate opportunity to challenge what may be discriminatory PPO behavior that could violate antitrust laws.

Welcome to the world of insurance discrimination, where insurance companies hand out PPO fee schedules like they’re playing favorites in a middle school dodgeball game—and you’re always picked last.

Let’s dive into the legality, ethics, and real-world strategy behind PPO fee discrepancies—and how dentists like you can push back.

Is It Illegal for Insurance Plans to Pay Different PPO Fees to Different Dentists?

Short Answer: No, but it can cross a legal line.

PPO insurance plans are, for better or worse, allowed to negotiate fees independently with providers. This is known as contractual freedom—they’re a business, and you’re a business, and both parties can agree on mutually accepted terms.

But what happens when they start paying your neighbor significantly more than you, even though you provide the same services with equal or better quality?

Now we’re potentially stepping into antitrust territory.

Antitrust Law & “Restraint of Trade”

Under U.S. antitrust laws, particularly the Sherman Act, any unreasonable restraint of trade is prohibited. While antitrust laws are more commonly used to prevent monopolies or price-fixing, there's a lesser-known clause that could be applicable in PPO discrimination:

Insurance companies cannot engage in discriminatory contracting practices that intentionally or systematically disadvantage certain providers in the marketplace.

This falls under the concept of a "restraint of trade", especially if the PPO payer can’t justify why one dentist is reimbursed significantly higher than another in the same region, for the same procedure, under the same plan.

According to one former insurance executive, such actions can “raise red flags” and could potentially be challenged if they:

• Have no clinical or geographical justification,

• Are based on favoritism or retaliatory contract practices,

• Or significantly impair a dentist’s ability to compete fairly in the marketplace.

What If a Patient Shows You a Higher Fee Schedule from Another Dentist?

Let’s be crystal clear: you cannot collude, share fees, or trade schedules with other dentists. That would violate antitrust laws and open up a Pandora’s box of legal trouble.

However, if a patient brings in a legitimate EOB or treatment plan from another office, perhaps while seeking a second opinion, you’re in the clear. That patient obtained the document legally. And if that EOB shows that Dr. Neighbor is getting reimbursed $1,500 for a crown you only get $950 for, it’s perfectly reasonable to say:

“Dear Insurance Company, please explain why you are paying other contracted providers significantly more for the same service, under the same plan, in the same ZIP code.”

It’s a fair question, and asking it does not violate antitrust laws.

Using Discrepancies to Negotiate Higher PPO Fees

If you’ve come across a legitimate EOB showing a higher reimbursement rate at another office:

1. Document the Evidence. Keep a copy of the EOB or treatment plan.

2. Write a Formal Letter to the Insurance Plan. Ask for a fee review and cite the discrepancy.

3. Use the Language of Discrimination. Highlight how this difference in fee schedules could create an unfair competitive environment.

4. Avoid Any Mention of Other Providers by Name. Protect yourself from claims of fee-sharing or collusion.

5. Stay Professional and Persistent. Insurance companies are far more likely to respond to firm, documented inquiries than to emotional venting.

Strategy Tip: Learn from Their Patterns

Many insurance companies have tiers of fee schedules that they won’t openly admit to. Some of these tiers are based on:

• Volume of claims submitted,

• Geographic regions (which are often not fairly calculated),

• Credentialing status,

• Contracting through umbrella networks.

The problem is that these justifications are often vague, and the actual logic behind the tiers is rarely transparent.

If you’re being underpaid, and your neighbor is making more, you can (and should) challenge this. It might not lead to an instant bump, but it will put your name on the radar—and show you know your rights.

The Ethics of Fee Negotiation: Stay Clean

Here’s your golden rule:
Negotiate privately. Never share your fees. Never ask others to share theirs.

Insurance companies want to prevent fee collusion. That’s why they include anti-collusion language in PPO contracts. But they also don’t want you to know that fee discrimination, if not clinically justified, can be challenged—especially when patients are the source of your intel.

Use what you know. Keep it ethical. But don’t let an EOB fall into the recycling bin without realizing it could be a golden ticket.

Quick Recap: What You Can and Can’t Do

Navigating dental insurance regulations can feel like walking a tightrope. Here's a quick breakdown of common actions dental professionals consider—and whether they're legal, ethical, or strategically smart.

1. Sharing Your Negotiated Fee Schedule with Another Dentist

🚫 Legal? No. This violates antitrust laws and is considered illegal.

🚫 Ethical? Also no—it compromises professional integrity.

🚫 Strategic? Definitely not. It can open you up to serious consequences.

2. Using a Patient-Obtained EOB to Ask for Higher Fees

✅ Legal? Yes. If the patient brings you their Explanation of Benefits (EOB), you can use that information.

✅ Ethical? Absolutely. It's transparent and patient-driven.

✅ Strategic? Very. It gives you a legitimate reason to request a fee review.

3. Calling Out Insurance for Unexplained Fee Differences

✅ Legal? Yes. Asking for clarification is within your rights.

✅ Ethical? Yes. You’re advocating for fairness and accuracy.

✅ Strategic? Definitely. It shows you're paying attention—and willing to push back.

4. Asking for a Fee Review with Supporting Documentation

✅ Legal? Yes. This is a standard, accepted practice.

✅ Ethical? Yes. It’s based on facts and patient care.

✅ Strategic? Very much so. Documentation strengthens your case.

5. Mentioning Other Providers by Name in a Fee Complaint

⚠️ Legal? Risky. It could lead to unintended legal consequences.

⚠️ Ethical? Questionable. It can be seen as unprofessional.

❌ Strategic? No. It often backfires and undermines your credibility.

Final Thought: You’re Not Being Difficult—You’re Being Smart

If a patient brought in a medication list that showed their pharmacy charged them double for the same drug compared to another store, they’d raise hell. So why should dentistry be any different?

Dentists deserve transparency, fairness, and leverage in a system that is often intentionally opaque. Just because PPO plans are “allowed” to negotiate different rates doesn’t mean they should do it without justification.

And when they do, you can and should fight back—with evidence, professionalism, and a working understanding of the laws they’re hoping you don’t know exist.

Need Help Negotiating Fees the Right Way?

Veritas Dental Resources has helped hundreds of practices ethically and strategically negotiate PPO fees with consistent success. If you suspect you're being underpaid—or just want to get paid what you're worth—we can help.

Visit www.veritasdentalresources.com for personalized help.

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