Introduction: A Familiar But Avoidable Surprise

It’s a common and frustrating scenario—Mrs. Johnson receives a composite filling on a molar, fully expecting her insurance to cover it based on your office’s verification. Weeks later, your billing coordinator delivers the news: her insurance applied an alternative benefit, downgrading the procedure to an amalgam. The result? A surprise balance that she never saw coming. Now she’s upset, confused, and less trusting of your office’s financial transparency.

But here’s the truth most practices miss: this scenario could have been avoided—not just with better communication, but by proactively negotiating the alternative benefit fee schedule itself.

Yes, PPO contracts often bury this detail—and most dentists never touch it. Today, that changes.

What Are Alternative Benefits, Really?

Alternative benefits (also known as downgrades) occur when an insurance plan approves a less costly version of the procedure performed—commonly substituting amalgam for posterior composites, or full dentures for implant-retained solutions.

While the primary fee schedule might be negotiated, the reimbursement amount for downgraded services is often left untouched. That’s a critical oversight. Why?

Because when a plan only agrees to pay for a downgraded procedure, the patient's out-of-pocket responsibility becomes the difference between the dentist’s fee and the low reimbursement for the downgraded procedure—which was likely never negotiated.

The Hidden Opportunity in PPO Negotiations

Most dentists negotiate the obvious:

• Prophylaxis

• Exams

• Fillings

• Crowns

• Endo

But here’s the hidden opportunity: You can negotiate alternative benefit fees separately.

Just like primary fees, alternative benefit schedules are adjustable. If left at their default levels, they often reflect reimbursement rates from over a decade ago.

Negotiating higher alternative benefits doesn't just help your bottom line—it helps your patients pay less. A win-win.

The Financial Impact of Ignoring Alt Benefits

Let’s use an example:

• Procedure: Posterior Composite (a white filling on a back tooth)

• Your Usual Fee: $275 (this is what you'd normally charge without insurance)

• Primary PPO Allowed Fee: $200 (what the insurance company has agreed to allow for this procedure)

• Alt Benefit PPO Fee (Before Negotiation): $120 — the PPO applies an alternative benefit, paying as if you did a cheaper amalgam (silver) filling

• Reimbursed by PPO (Before Negotiation): $120 — insurance only pays based on that downgraded amount

• Patient Pays (Before Negotiation): $155 — the rest is the patient’s responsibility

After You Successfully Negotiate with the PPO:

• Alt Benefit PPO Fee (After Negotiation): $160 — you convince the PPO to increase the reimbursement for this downgraded procedure

• Reimbursed by PPO (After Negotiation): $160 — insurance now pays more

• Patient Pays (After Negotiation): $115 — patient owes less out of pocket

✅ Thanks to that $40 increase in the alternative benefit rate, the patient’s bill drops by 26% — and the best part? You don’t have to lower your usual fee or cut corners in patient care.

That $40 increase in the alt benefit rate reduces the patient balance by 26%—without reducing your fee or cutting corners.

How to Negotiate Alternative Benefits

Negotiating alternative benefit fees follows many of the same steps as traditional PPO fee negotiation—but with a few key distinctions.

1. Request the Alternative Fee Schedule

Ask the payer (MetLife, Delta, Aetna, etc.) for a separate listing of the alternative benefit reimbursement rates. If they resist, request it under the pretense of estimating patient co-insurance accurately.

2. Identify High-Impact Codes

Focus on codes where downgrades commonly apply:

• D2391–D2394 (Posterior composites)

• D6065–D6078 (Implants, when downgraded to bridges or partials)

• D2750 vs. D2790 (crowns downgraded to base metal)

• D2950 (build-ups) where coverage is limited or downgraded

3. Demonstrate the Burden on Patients

Frame your negotiation not as a doctor asking for more—but as an advocate for the plan members' out-of-pocket protection. Emphasize that outdated reimbursement rates on downgraded services result in larger patient balances, triggering complaints and provider dissatisfaction.

4. Present Market Data

If possible, submit comparative fee data from other carriers or from tools like FAIR Health, Veritas Dental Resources, or ADA fee surveys. Show that current alternative benefit rates are below standard and do not reflect actual clinical costs.

5. Offer Reasonable Increase Proposals

Don’t expect massive jumps, but aim for 10–25% increases in the alt benefit schedule. Insurers may be more flexible here since these fees are not as publicly scrutinized or widely requested.

Protecting Trust and Improving Case Acceptance

A higher alternative benefit:

• Reduces surprise balances

• Increases patient satisfaction

• Boosts trust in your practice

• Leads to higher case acceptance

Patients don’t walk away angry because they weren’t blindsided. And when they’re happier, they’re more likely to say yes to treatment—and refer others.

Final Thought: Stop Letting Alt Benefits Be an Afterthought

Alternative benefits aren’t just a policy quirk—they’re a silent profit leak and a major cause of patient dissatisfaction. By negotiating these rates like you would any other, you shift the dynamic in your favor.

Insurance carriers will push back. But now you know: it’s negotiable. And it’s worth it.

So next time you sit down to renegotiate fees, remember this: you’re not just fighting for your own profitability—you’re protecting your patients from a surprise bill they never should have received in the first place.

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