Introduction

Negotiating better PPO reimbursement rates is a priority for many dentists looking to improve profitability. However, understanding the legal and strategic rules of PPO negotiations is crucial to avoid compliance issues. One common question is:

"Can I negotiate PPO fees as a group with my study club members?"

While negotiating individually is perfectly legal, group negotiations—depending on how they are structured—can raise antitrust concerns. In this article, we’ll break down:

• The rules for PPO negotiations

• What’s legal and illegal when negotiating fees

• Alternative strategies for group leverage without violating the law

1. Can You Negotiate PPO Fees?

Yes! Many dentists successfully negotiate higher reimbursement rates, especially when they:

• Have a high patient volume with a particular PPO.

• Offer specialized or unique services (e.g., sedation, full-mouth reconstructions).

• Are in an underserved area where the PPO needs providers.

• Are willing to drop a plan unless rates improve.

Action Tip: If you haven't negotiated your PPO fees before, start by requesting a current fee schedule and comparing it to your UCR fees. Then, submit a fee increase request for low-paying procedures.

2. Is It Legal to Negotiate as a Study Club or Group?

No, collective fee negotiations are illegal.

Under the Sherman Antitrust Act, group negotiations by independent businesses (such as a study club of private practice owners) could be seen as price-fixing or collusion, which is illegal. The Federal Trade Commission (FTC) prohibits independent dentists from jointly negotiating fees, as it could unfairly pressure insurance companies and reduce market competition.

Illegal Negotiation Activities

• A group of independent dentists negotiating together for higher fees.

• Coordinated fee-setting among private practice owners.

• Boycotting PPOs together unless they agree to higher rates.

Exceptions (When Group Negotiations Are Allowed)

• If the group is part of a single business entity (e.g., a DSO or multi-location practice), it can negotiate as one unit.

• If dentists form a legally structured Independent Practice Association (IPA), they may negotiate collectively within specific guidelines.

• Dentists can share fee negotiation tips individually, as long as they don’t collectively negotiate with PPOs.

3. How to Use Group Leverage Without Violating Antitrust Laws

While you cannot directly negotiate as a study club, you can use collective strategies to strengthen individual negotiations:

• Share PPO Fee Analysis (Legal)

  • Study club members can privately compare their individual PPO fee schedules (without negotiating as a group).

  • If one dentist receives higher fees, others can use that as leverage in their own individual negotiations.

  • Example: "I recently negotiated with PPO X and got an increase in crown fees. You might want to request the same!"

• Individually Drop Low-Paying PPOs (Legal)

  • If multiple dentists independently decide that a PPO is not worth the write-offs, they can each drop participation separately.

  • PPOs may reconsider their fee schedules if many providers exit individually (not as a coordinated boycott).

  • Action Tip: Before dropping a PPO, check your patient base to see if it significantly impacts your practice.

• Join a DSO or IPA for Group Negotiation Power (Legal)

  • DSOs (Dental Support Organizations) can negotiate as a single entity, leading to better fees.

  • Forming an Independent Practice Association (IPA) with legal guidance may allow collective negotiations.

  • Key Difference: An IPA must follow strict legal structures to avoid antitrust violations. Consult a healthcare attorney before forming one.

4. What to Say When Negotiating PPO Fees

When negotiating, focus on why you deserve higher fees, not just that you want them.

• Highlight Your Value:

  • High production volume for their plan.

  • Unique services (e.g., implants, sedation, same-day crowns).

  • Low competition in your area (leverage if there are few providers).

• Be Willing to Walk Away:

  • If a PPO is too unprofitable, consider dropping it.

  • Some PPOs will offer higher rates to keep you in-network.

• Ask for a Tiered Fee Schedule Review:

  • Some PPOs have multiple tiers of reimbursements based on provider status.

  • Request to be moved to a higher-tier reimbursement level.

Final Takeaways

• Yes, you can negotiate PPO fees individually—and you should!

• No, you cannot negotiate fees as a study club—this violates antitrust laws.

• Alternative group strategies:

  • Share negotiation success stories with peers.

  • Individually drop low-paying PPOs.

  • Consider forming a DSO or IPA for legal group leverage.

By using smart negotiation tactics while staying legally compliant, you can improve your PPO reimbursements without violating antitrust laws.

Would you like a PPO negotiation script to help guide your fee increase requests? Let me know! 😊