'Insurance Basics and Tips to Boost Production' with Santosh Rohira, CEO of BEANbite

Stop and think twice before you start the credentialing process.

One thing, one point to make a note of here and the sellers can.

Take that into consideration is credentialing process takes 30 to 120 business days. Some brokers will not allow the buyer to start the credentialing process.

Until the actual closing date as this could interrupt the operations of the current owner's practice and we value that. So be mindful of those factors before you start your credentialing process. Like all things in life, each practice sale is unique and so one needs to be able to bend to the circumstances at hand.

With the above given facts, there are two options that a buyer can consider. 1. Start the credentialing process after the close of escrow. Credential with delta only if your practice is purely Delta based and you have a huge delta base. Rest of the insurances can be credentialed after the closing date. And I really like this option because if you credential with the rest of the insurances after the closing date.

One is you're going to get paid at your UCR fee.

For all the rest of the insurances which gives you an extra wiggle room to not push or pressurize your patients into starting same day treatments. That way you're getting reimbursed on your basic diagnostic and preventative services, letting the patients ease into your practice. And yet you're getting paid at the UCR fee which is almost, I believe, double that of a contracted fee schedule. Most sellers like to go with this choice and this does not cause any alarm to the current office staff, but make sure you submit a copy of your W9 form along with every claim that you submit to avoid delays because your tax ID is going to be new and the insurance companies new to have it registered in their database.

Option 2 Start the credentialing process well in advance.

This is not the seller's choice, but definitely the buyer's choice. This is a very good choice only because the seller, the buyer, is ready to start billing in the right way from day one. Claims correctly claims are processed as in network.

The only risk is that insurance companies may start sending paperwork to the practice location before the close of escrow which can raise an alarm to the current dental office staff, make them get worried if they are going to be retained or they're going to be let go because of the new practice owner taking up the practice.

Well when we start the credentialing process in such cases where the buyer is anxious and he does not want to Wait. We normally let the insurance companies know this practice sale is confidential. Please do not contact the dental office directly. Contact.

The dentist who who is purchasing the practice location or the credentialing manager most often and 99% of the time all the representatives are very mindful of this. But no one can take guarantee of the presence of mind of the insurance companies and their representatives. If they fail to do so, the seller may get agitated. So be careful with your choice.

A lot of times brokers are not happy with this option because if the practice sale fails then this could cause a disturbance with the.

Current provider's business operations. Well, I'm not in complete agreement this is a conflicted area, but in my opinion, if the practice sale falls out and the credentialing process is completed, there is an option to let the insurance companies know to suppress the directory listing on the website so the provider is not shown on the website as an in network provider. In such by doing this, the patients are not misguided by the current provider at that practice level location.

After all, the buyer is the one who's going to be stuck with dealing with the claims issues once the practice sale is done. So I really favor option two and it's a good idea to consider this option as well.

But yet again, each practice sale is unique. I recommend that you call the insurance companies yourself. Do your ground survey before you make a final decision. It's a tricky situation and not many buyers are even considering this fact up till a day or two before the close of escrow.

As discussed previously, I was mentioning About NPI Type 1 and Type 2.

NPI. NPI is required by every healthcare provider transmitting health information in connection with standard transaction in electronic form.

And every such provider needs to obtain an npi.

Obtaining an NPI is required by HIPAA for electronic transactions. If you answer yes to any of the following questions, you are required by federal law to obtain an npi. Do you submit claims electronically? You use a clearinghouse, do you submit claims attachments electronically? Or even at the very basic check eligibility for your patients online? In such cases, you definitely need to obtain an npi.

But then what kind of NPI do you need? MPI type 1, MPI type 2? This has been a question that a lot of providers have been asking me for a very, very long time.

Well, if you are a single provider and you're running a solo practice and you have no other providers in your practice, you don't need to get an MPI type too. You can be billing under your NPI type using your Social Security. But obviously in this scenario you're exposing yourself to a lot of liabilities. Please consult your CPA in regards to this. Most often now I see single providers forming a business entity and doing their billing through a business entity. If you are forming a business entity and you are going to start billing, billing out insurances as an incorporation, it is absolutely mandatory that you get an MPI type 2. The way I remember this is type 1 is for me, always. Number 1 is for me because I'm the rendering provider. Type 2 is anything other than me, so it's secondary. So that's for my entity. That's how I remember it. It's very simple. So.

If you are running your dental practice and billing insurances as a business entity, make sure you get your type 2 NPI ready for all other providers. Whether he's an associate dentist or an owner, he has to have an NPI Type 1.

Next, which insurance should I credential with? Well, this is a very, very important question and it is a question that providers need to consider based on their zip code and the area where their practice is located. If you are new in startup practice, look at the demographics, look at the earning capacity of the people there. Call for those statistics if the statistics are average. In that case, you may want to consider government plans and some HMO plans in order to encourage patients to come to your office. If your practice is in a very well to do area, like let's say Bay Area where there are a lot of IT companies, you're probably going to attract a lot of that crowd and most of them have dental insurance from good insurance companies. You may want to sign up with those come.

So normally if you're involved in a sale of practice and you're acquiring a practice, usually the best guidance is to follow the same template of the seller and transfer that to yourself. Make sure you credential yourself with those same insurances that the seller currently has. Another guidance is if it's a startup practice, you're not very busy, you're trying to boost your practice. You may want to consider adding more insurances. You may want to consider signing up for government plans, but this is a choice that you have to discuss with your consultant.

Again, should I credential with all or some PPOs? Well, it again goes back to the previous question, is it a startup practice or an existing practice? Are you a fee for service and Delta practice only? Remember, if you're purchasing a Delta practice only, all providers who purchased a practice who became credentialed with Delta prior to 2014 were able to be premier providers only. So make sure if you're buying a practice which is mostly Delta, you will not be getting reimbursed on the premier fees. You're most likely going to get reimbursed on the PPO fees, but this applies to only about 15 or so states in the whole of.

The nation. The rest of the states do have some flexibility with allowing general dentists to be premier providers only.

So after all that, if you decide to credential with almost all PPOs, choose wisely. Make sure you have called for the contracted fee schedules. Based on those fee schedules, determine if you want to credential directly with an insurance or use a third party network. A third party network may give you an advantage of getting a higher fee schedule and still seeing patients as an in network provider.

Next, very often large practices who have multiple providers working there ask me should I credential my associate dentist or should I not credential? My advice has always been credential all your providers with Delta across the board. And this is only because of the no assignment the benefits that Delta has. But yet again that is a choice that the practice owner makes and how the practice has been for years and if they are making a change to not accept Delta patients at all. But in the event you are a Delta only practice then I recommend credential all your providers with Delta and all your specialists should not be credentialed with any other insurances except Delta. And the reason is specialists are providing a specialized kind of treatment. You need to create a value around the treatment that they do and you need to make sure you're correcting the right fee for the treatment and experience that they are providing.

So if they are out of network patients understand their fees will be higher and their experience to pay and this is going to help boost the practice production and net collection. All other providers, general dentists who are actually performing some kind of treatment for your patients and patients are coming and looking for those providers. Go ahead and credential them with all insurances because they are coming to your practice because your practice is in network.

The advantage of doing this is it gives immense visibility on the Internet and the insurance websites also do list all the providers on their website listings. So this could bring a lot of patients to the practice.

Here is A list of PCOs which are good to credential.

I would say a must is Delta Dental. Again because of the same reason.

No assignment for out of network providers. I've added Anthem Federal plans and some other insurances that do have federal plans like Humana and the reason is federal plans have no out of network benefits. If a provider is out of network all the payments the claims will either not get paid or will go to the patient.

So again, I'm going to repeat myself. Federal plans either have no out of network benefits or no assignment of benefits. In case of no out of network benefits, you're not going to be able to see that patient as a provider because you're not going to get paid anything at all. You will have to see that patient as a cash patient for no assignment of benefits. With these federal plans it's just like Delta, the payments go to the patient and with regards to recommended insurances, here is a list Aetna, Cigna, Guardian, medlife, NEHA Connection Dental Dental bra, United Healthcare, Dentamax, Carrington Plan Platinum and Assurance Sun Life Note Carrington Platinum vs Carrington PPO Think twice before you credential with Carrington PPO and I'm going to discuss this in a few slides.

Later. The reason why I'm mentioning this is sometimes Carrington PPO has a better P schedule than GIHA Connection center and they both have almost a similar list of third party rental networks that they share. So you may want to consider becoming in network with character PPO in those cases.

Here is a slide for providers who are interested in HMO ppo. That was just for today.

I really like all providers to get onto any discount plan available out there of course after reviewing the fees that they provide. Carrington is a good one. Veterans Discount plan is another good one and Aetna is also a good one. With Aetna they allow you to go ahead and see the patients at a 20 to 30% discount off your UCR fee. So go ahead and check those plans and add them to your current.

Insurance profile. What they look like.

Providers ask me do I have to credential with Delta? What is my option here? Well your option is either you credential and you take both give credential as a PP provider or you stay out of network and collect full upfront fees from the patient based on your UCR only three providers can be credentialed as Premier. Three specialists can be credentialed as Premier only and these are Endo, Perio and Oral Surgery. Ortho and Pedo are considered to be excluded excluded from this Premier only status and they follow the General Dentist rule.

For doctors that are buying a Delta only practice or having a major patient based from Delta.

This is an eye opener for you and you can see the difference in the collection that you're going to make.

Providers credentialed prior to May 2014 had the order of retaining their Premier only status, but providers credentialed on or after May 2014 have to be credentialed as Premier and PPO providers. The way I look at this is that a provider needs to basically consider himself only as a PPO provider and the PPO status is a mere fault.

This is because the number of patients that have Premier plan is less than 1%. So most probably for 99% of your patients you're going to get paid at a Delta PPO fee and only 1% of the patients they're going to get paid at the Delta premium fee. Whereas providers before 2014 were able to get the Premier fee whether the patient had a Delta PPO or a Premier flood. As you can see in the slide for PPO patients, the provider who is a Premier only provider is still getting paid $99, which is almost $20 more than what.

The Delta P what a provider is currently making if he gets credentialed Now.

A lot of times providers tell me that I am already credentialed at with all the insurances at the previous location where I was working as an associate dentist, can I not just transfer my credentials to the new practice location?

Well, the answer is no, although you are credentialed but you're not contracted at your new practice location. Some insurance companies may allow you to just fill out a quick ad location form and get you in network within 30 days, but some of them will have you fill out a full credentialing application. The way the insurance companies work is they have three pointers based on which they consider a provider to be in network at a particular office location. One is a billing dentist and his NPI type one in case he is a solo provider or his NPI type 2.

In case his entity is a billing provider, the rendering dentist matching his license number and entity type 1 and the treating location in case the insurance companies are not able to draw a contractual relationship between three of the above pieces of puzzle, the claims get denied and processed as out of network. Most commercial insurance companies now process claims under the rendering provider rather than the billing provider.

Now you may ask why should I stay on top of my RE credentialing and when should I do the RE credentialing? Well, as a part of the new healthcare change request, a lot of insurance companies are now more regularly sending out the RE credentialing paperwork to the to the dental offices. Please make sure to give a heads up to your office staff to watch out for these the credential requests are not tied up to renegotiations of your fee schedules or changes in the fee schedules. They are just requests to keep your current contract in good standing. But if you have not negotiated your fee schedule in the last two years, evaluate and rethink your position. Maybe even consider joining this particular insurance through a third party network. Talk to the insurance area representative and tell them, hey, I have not received a fee increase in the last 23 years. While I'm getting my RE credentialing done, is it possible for you to provide me a better fee schedule? Don't hold on to the paperwork just because your decredential is not completed. Just because your fee revision is not completed that needs to be sent in promptly because we do not want to mix up your RE credentialing with fee negotiation, but it's a good time to definitely discuss your fees with the insurance representatives.

Contracted doctors must return the re credentialing paperwork promptly only because they don't want to get bumped out of the out of the network. If you get bumped out of the network, getting back is not going to be easy and you may have a whole set of claims that are getting rejected and you're going to be having to deal with all of those rejected claims.

It can take months to get pulled back into the network and re credentialing. As you know you will have to do a full new credentialing. As you know it takes 30 to 120 days.

Re credentialing is a time to review and update a few erroneous or conflicting information on your website, your email address or even in regards to the fact that you may have a new malpractice claim against you. So such things need to be reported at the time of re credential.

Definitely do not miss out on the Delta RE credential.

You have to be very prompt in sending out your Delta re credentialing paperwork especially if you are a Premier OD provider. This is because if you lose your Premier only status you are not going to be able to get it back and this can cost about $100,000 for you on an annual basis. So definitely if you are working with Delta and you are a Delta provider, do not get bumped out of Delta. Especially if you are a Premier only provider for all TPO providers. Again the same problem, Delta is not providing assignments of benefits so you will end up following up with your patients for these payments. So make sure you take care of your Delta re credentialing promptly.

Re credentialing with contracted third party administrators. Don't miss this again because as you know, if you are contracted with a third party administrator such as Connection Dental or Delta Max, not only will you get terminated from Connection Dental, but your contracts will be pulled back from dozens of other companies that are attached to this single contract. If you get bumped out, then you will find yourself with a whole bunch of claims that are getting rejected and fall under this umbrella network. For example, if you're taking.

For example it is now taking four to five months to complete the credentialing with all patients under Deltamax. Deltamax is really lagging behind in their credentialing process. So if you get bumped out of this umbrella network, all your claims will start falling back.

So be very careful with dealing with third party requests for re credentialing. Keep your front office staff updated and they need to help you fill out all this paperwork and send it out promptly.

Also note re credentialing is done with once in three years.

But it does not necessarily coincide with the dates you started the credentialing process for your dental practice. It actually starts with the with the date when you first sign a contract. Even if you were credentialed with Delta at a different location. Let's say for example that you have a relatively new practice that you just opened six months ago and you recently signed a contract to participate with this insurance company. You may receive a notice for recredentialing within three months and you must be wondering what is going on.

Well, your initial contract the very first time you got credentialed with them was about three years ago and that's why they are sending you this re credentialing request. You may assume this is an error because you know that your contract is only six months old. Keep in mind that you have been showing up as in network associate at another location prior to your new contract. You signed at your new office location.

Regardless if you think you're due or not, I really suggest that you print promptly send out all your decredentialing paperwork without any delays. It doesn't hurt to get re credentialed even if you're not due or even if you think you're not due.

Fee Schedule Negotiations A lot of providers are looking into this now, especially because they are under the COVID 19 lockdown. They have a lot of wiggle room to check their fee schedules. It's very important to review this.

At least once every once every year to see if you're able to negotiate your fee schedules. Only about half the population has dental insurance. While we are so busy discussing fee increases, we should remember there are several other people who do not have dental insurances and most DSOs are targeting this group of patients as well. They are providing incentives for these patients who do not have insurance to come to their office. Some practices, especially large DSOs have now incorporated in house discount plans for patients without insurance. So don't put your hardcore completely out onto fee schedule negotiations. Look into establishing an in house discount plan. This is not a dental insurance and so therefore it's not going to be controlled by a state insurance commissioner. The Practices the practice most DSOs who have in house discount plans sell an annual discount plan that includes at least 2 flat rate we call business. So just imagine you are encouraging your patient to come for two recall visits and you're giving him a flat rate of $80 per visit. I would love to go to a practice that is going to be giving me such an offer. Typically the discount plans are associated with providing only a 20% discount on the full UCR fee and fluoride and is offered for free. Other items that are incorporated into the discount plan are tooth whitenings that are provided at a very very good fees for these patients. So go ahead and see if you can start getting yourself set up with some kind of a good discount plan.

On an average dentists are apart from this. You can then consider.

Reevaluating your fee schedules with the PPO insurances.

The ability to negotiate a fee schedule really depends on what the insurance network needs and if they need to cover any gaps in that area.

Most insurance companies are willing to negotiate, but worse comes worse if they have way too many dentists in that area. They may say there is no wiggle room for negotiation. At that point you need to reconsider your participation status and re evaluate maximizing your PPO network structure.

The Steps to a Better.

There are many specialty specific and practice specific nuances that a dentist needs to consider as a part of their fee schedule negotiation.

You need to think and ask yourself how many PPOs is my office contracted with? What are my top 20 to 30 codes that drive the major production for my practice?

What's the exact list of insurance companies that drive the revenue for my practice? Do I really need to negotiate or can I just drop that insurance and pick up a third party network? Or just maximize my revenue by strategizing my PPO network by sending some opt out forms so really? Before you start negotiation, consider these facts.

How do you determine if you need a negotiation solution?

Sometimes one or more insurances.

Can better be resolved by structuring your current PPO network. I'm going to give you an example. A lot of practices are in network with Emeritus and Emeritus is one of those insurances that does not have very good reimbursement streams. You may want to consider, hey, I'm not having a good fee schedule from that, why don't I just drop this and pick Emeritus up through an umbrella network such as Connection Dental? You'll notice there's almost a 10% difference in the fee schedule on all the procedures and we have been seeing this with all the providers that we have been credentialing. So go ahead and prepare a spreadsheet, do your comparison and evaluate the insurances that you're currently in network.

You may want to decide to terminate Ameritas and go ahead and just be in network with Current Dental alone. But be very careful. Some insurances have clauses, let's say if a provider was ever credentialed. We will not pick them up for a particular time frame. It could be a waiting period of one year or two years and insurance company representatives are not very willing to reveal the real truth behind this. But if your representative is the if you have a good rapport with your representative, he or she may be willing to give you some guidance on how to work this fee negotiation out for yourself.

Additionally, it is good to be informed that sometimes if you by mistake decide to drop a network with the higher fees when you want to get back, you tell the representative, hey, I made a mistake, I want to sign. Get my contract back. You may not get back the same fee schedule that you were in network with previously, so be careful. Think twice before you make the decision to terminate an insurance.

When negotiating your fees with the insurance company representatives, please I really urge you to to be mutually respectful to each other because they are also bound to work with the principles and guidelines put forth by the insurance company. Try to understand the rep stance and put forth a creative solution which is mutually agreeable.

Do your homework Prior to starting your credentialing process, check with yourself and see what are your key goals during the negotiation process. What is your leverage here? Do you have a third party network that you can join or if need be and the time comes are you ready to terminate a plan? Identify your top 15 to 20 codes that you commonly use. Most practice management softwares are able to pull a report for you of the top 15 or 20 codes that you commonly use the practice management software that even capable of telling you how many times you use that code and the average fee that you have been selling that code at. So check with your practice management software representative and ask them to help you pull these reports. Get a list of the top 1520 codes ready for yourself before you start your negotiation process.

Give yourself a clear and realistic understanding of what success looks like. Don't be disappointed if the insurance company representative say well, I'm able to negotiate only 10 or screening.

Identify your next best alternative solution to negotiation. When you are willing to walk away. Don't be disappointed because you tried. It's always best to try rather than not negotiate at all.

One factor that most doctors forget to review prior to starting their negotiation association is evaluation of their UCR fee schedule. I have seen so many providers in my work history that have their UCR fee schedule set even below the 50th percentile of the ADA UCR survey. I can't imagine and I don't know how providers miss such an important factor. Please go ahead and log into your ADA account, sign up and pay that $300 to get your fee schedule. To get the ADA UCR, see where your current UCR fees stand. It's so important to be competitive in the market. You don't want to be leaving any free money on the table and not pocket it. Go ahead and check that. Ask your consultant to prepare a fee schedule analysis for you based on your zip code.

A good fee schedule analysis and change can help boost the production and collections of a practice to up to 5 to 8% on an annual basis. When you enterprise your fees, you're at the risk of leaving a lot of money on the table. Remember, fees are always high in the patient's eyes. So what you are doing here is not only just selling your service, but also your experience. Dr. John down the road he could have this experience of just two years and his fees may not be so high. But you could be experienced and having 10 years of history in the dental industry. Why would you sell your services at a lower rate? You have proven success results, so go ahead and value yourself. Go ahead and take pride in your services and set your UCR fee to the right place. Even so, it's very very necessary that you raise your UCR fee on an annual basis. Even if it is for a small minute. Raise your as small as 1.5% on an annual basis.

Regardless of the past, most practice now need to start rebalancing their fee schedule. It's not possible that if your practice fee schedules are starting at 50% of the ADA UCR survey that you suddenly increase it and bring it up to 80%, it's going to cause an alarm with your patients. So the best thing to do is slowly but gradually start rebalancing your fees. By rebalancing I mean is adjusting your lower fees slightly upward and your higher fees at a very small but moderate rate. The end result could be you're going to have a very balanced fee schedule. This may take 2, 3 years for you to balance, but it's never too late to say start.

Additionally now since COVID 19 has started, a lot of patients are losing their jobs and along with the jobs they are losing their dental insurance as well. So having a well balanced UCR fee is going to be able to help boost your practice production. Think twice. Most patients are now.

Just discount and coupon oriented, so it's a good time to get that discount plan incorporated in your practice. Work with some companies that help you establish a in house discount plan. Don't forget that.

And most patients are looking at public resources available such as FairHealthConsumer.org is a public consumer website that provides fee data by zip code and percentile at no charge. Although this website is not permitted for use by dentists or dental office staff or dental consultants is available to public. So make sure you're at least letting your patient know that you're charging as per your zip code and you're not either way too high for that area or way too low. There are however other resources that doctors can use to compare their fee schedules, one of which is National Dental Advisory Service. Another resource is the ADA Survey for Dental Fees. Another resource is the Wasserman Medical Academy. Go ahead and look for these, Google it up or speak to your dental consultant and set your fees to a rate where you are able to justify your service.

Apart from this, when you send your.

Request to insurance companies for negotiation, if your UCR fee itself is low, there is no room for the insurance company to further increase your fee schedule. You need to set and report these UCR fees on every ADA claim form so that when you are at the point when you want to negotiate the fee schedules, the insurance Companies know Hey, Dr. John has been reporting $110 or $136 for his pro fees but we have been paying him only 64. We are only paying about 50% of his UCR fees. At that point they might just give you a good bump in your fees. So go ahead and and keep a good base UCR fee for insurances to compare. A lot of times when we start working with negotiations, insurance companies want to see what is the provider's current UCR fee. By reporting these UCR fees in all your claims, the insurance companies are setting a national database for.

All the providers in that zip code and they're going to do a comparison. If you are going to start filing your claims with your contracted fee schedule, they are not going to be able to make that comparison. So please work with your practice management software representative and make sure your claims go out electronically with the UCR fee. Although on the patient's ledger and account you're showing the contracted fee schedule and you're not going to be having extra write offs.

Next, examine your participation status. Most providers, when I ask them for a list of insurances they are currently contracted with so I can start their negotiations, a lot of them give me a list of 8 to 12 insurances. But what they fail to realize is that because of the current third party network relationships, there's a good chance that they are in network with three times that list. So I need that list in order to make sure that you are getting reimbursed at the right fee schedule. And if you are in network with a particular insurance with two umbrella networks, you are getting reimbursed on the higher of the two fee schedules. The way insurance companies operate is they will pay you based on the lower of the two fee schedules. So in this case you will have to send an opt out form to opt out with the from the lower fee schedule and make sure you're getting paid on the higher fee schedule. So work that out, look at those contracts and review them often. Another thing to make a note of is keep a spreadsheet with yourself. Make sure you have put dates on those as to when you last negotiated your insurances. Because most insurance companies allow negotiations to be done once in 18 to 24 months. Also another fact to remember is some insurances will not allow you to negotiate these schedules. Such insurances are MetLife Anthem Insurance. Such cases, you may really want to consider joining MetLife through Connection Dental because MetLife fee schedule may be way lower than the fee schedule that Connection Dental has. But remember, in order for you to be accepted to a third party network, it could take about 60 to 90 days and sometimes 120 days. And sometimes a lot of work goes on at the back with insurance representatives because they just refuse to add you because of several other reasons. You have to work it out on a step by step basis and clear up all the hurdles that are causing you to become in network with MetLife through connection debt.

Some insurance companies will be willing to negotiate a few codes with you. So if you don't have your top 15 to 20 codes ready, then how are you going to be able to present it to them to get that fee schedule increased?

Some insurances are able to negotiate the fees and provide a customized fee to your practice location only. So some insurances have fee schedules that are standard and they have three levels of fee schedules that if provider approaches them, you can give them level 2. Next time they approach you, they can give them level 3 of the fee schedule. But some insurances like Carrington and Sun Life will customize the fee schedule pertaining to your office. And unless you know your top 20 codes, you're not going to be able to submit them. You're not going to be able to make the best use of that negotiation.

My sincere urge is develop a matrix of the 10 big players for your practice.

Which drive the net revenue for your office. So for example your example accepting about 25 insurances, pick and choose the top 10 that could be driving the main revenue of your practice. Prepare a spreadsheet, put off the top 20 codes on those insurances and start your comparison from there.

With the next few slides you will see a few examples of successful negotiations and how we have done our comparison.

This is a real time success that we have for Guardian. As you can see, Guardian agreed to provide a fee increase to $36 from the old amount of 33, which is barely a three dollar increase. But when provider sees 10 patients for an exam, he is increasing his fees by $30. For 20 patients he's getting additional $60 and for 40 patients he's getting an additional of $120. On an overall, when a patient comes in for an exam trophy and FMX for 40 patients that he may be seeing throughout the year, he has just increased his net revenue by $800. And this is, mind you, this is just for X ray, exam and cleaning.

And I'm sure a provider is seeing at least 40 patients from Guardian on an annual basis. Even if you just calculate at the rate of three patients a month, just three patients a month, three times 12 is 36. So with 36 patients just with the basic exam, trophy and X rays, he is making additional $800. What about if he is going to start doing if you are going to start calculating his revenue increase from the services from the treatment that he does for these patients. So as you can see here for 40 patients out of which if he does even treatment for 20 people he is going to increase his net revenue by $2,880 over a period of the year.

So go ahead and try to get those fee scheduled negotiations going.

Umbrella companies have third party shared network relationships with several big players in the industry such as Dentamax, Carrington Rodion. Most of them have third party rental network relationship with big players like Atman, Cigna, Principal Amenities, MetLife, Anthem Liberty and many other players that drive the production and collections for our office. So review those. Call all these insurance companies, ask them to give you a list of all the third party networks that come under their particular umbrella network. Call Datamax representatives, speak to her, ask her to send you that list. Compare that list with your current participation and see if it makes sense to just drop one of those networks rather than even negotiate. Because if you try to negotiate, probably Principal is going to give you an increase of 3%. And when you do that calculation on an Excel spreadsheet, you'll realize by simply dropping the principle and using Dentamax you just give yourself a 10% increase in production rather than taking the effort to negotiate the fee schedule. So look at those facts and then start your negotiation.

Here is another example. Aetna offered a fee increase for a provider that we were working with and offered $79, whereas the the current contracted fee schedule with connection Dental was $83. Which provider or where in the world would anybody not decide to go ahead directly credential with Connexion Dental and drop Aetna? So think twice before you negotiate. Are you spending your time usefully or uselessly? Because sometimes you don't even need a negotiation solution. All that you need is strategize your current participation in such a way that you're making the best use of your reimbursement. Go ahead and send the termination letter to Aetna. But before you do, Aetna also has some other insurances that fall under its network. Recently Emeritus was added to that network. Make sure your part is if you're dropping Aetna, it's not disturbing your participation with other insurance companies. So re evaluate that before you make your final decision.

So this slide is in continuation with what I just said. When you are sending out your termination letter, make sure you evaluate.

And see if it's not disturbing your other network participations. Here I am discussing about opt out letters and I'm going to give you an example. Sigma participates in a third party network relationship with Dentamax as well as with Connection Dental. Now, usually from what we have seen, dentamax has a lower fee schedule than Connection Dental. If you are in network with Both on your EOBs, when you see the payments coming in, you'll see the EOB station. The allowed amount has been reduced to the contracted Dentamax fee schedule. @ that point you'll say, hey, wait a minute. My goal was to get in network through Connection Dental because that one was offering me a higher fees. You now need to contact the Dentamax representative, ask him for an opt out form for Cigna. SGMA falls under the shadows. They plan and therefore you will have to fill out that opt out form.

Send it to Dentamax. They will take three months to process that opt out. Until three months, you're going to be stuck with getting reimbursed based on the Dentamax fee schedule. A lot of times I tell my providers, when you are verifying eligibility for a patient, make sure your front office is asking for what is the fee schedule we will follow for this patient's treatment plan. This kind of setback can be mitigated at that point rather than when you receive your EOBs. So be very careful with that. The insurance landscape is changing drastically. A lot of providers are not directly in network, but rather indirectly. So your fee schedules and treatment planning will vary extensively based on your participation status.

Here is a list of insurances that negotiate and a list of insurances that do not negotiate. If you want, I can pass the slide on to everybody after the presentation.

One important factor that I would like all providers on this call to make a good note of is after your credentialing is done, please keep a close Watch on your EOBs because you may think that you're getting reimbursed correctly, but the real fact of the matter is the final claim processing EOB is what will tell you the real truth of how your claims are being processed. I had a provider who asked me to credential him with all insurances because he assumed that the seller was credentialed with all insurances. And he gave me both the EOBs and he told me this EOB belongs to that same patient from the same office. And.

When the seller was in possession of the practice in 2019.

As you can see.

The seller on 1025, 2019, he got reimbursed at $130. Whereas the buyer, when he was in possession of the practice in 2020, he got paid only $91. He called me back and he Said, why would I get paid at such a low fees? I said, as you mentioned to me, the provider was in network with Anthem. So we decided to make you in network with Anthem. But from the eob, it's very obvious the provider was not a participating provider with Anthem. Therefore he got paid on his UCR fee. Now this provider is probably going to be stuck based on Anthem's termination policy for one year with Anthem Blue Cross.

And its fee schedule. So be careful before you make a decision to credential, look at the fee schedules.

Here is another example of a EOB which I just mentioned a few slides before of how claims are paid. As you can see on this eob, provider wanted to get in network with Tentamax fee schedule. But the EOB has been issuing that the claim was processed based on the Stratos network Datamax network and therefore for a pro fee, the provider got paid.

Only.

$65. Whereas the fee schedule for Carrington Platinum or GIHA, if he had chosen, if he had sent out the opt out form promptly would have been $79. You see the difference here.

Provider is contract with GIHA, Carrington Platinum and Dantamax. Gheeha is giving him a reimbursement of $79 for a pro fee. Carrington is giving him a reimbursement of $84 for a pro fee, whereas Dentamax is giving only 65. Although he dropped out of Cigna, but the provider forgot to send the opt out form to Dentamax in order to be picked up either by GIHA or Carrington Platinum. So make sure you watch out for those EOBs. Look at them and your strategizing, your network participation to your desired goal. Thank you and I hope everybody enjoyed this presentation. I am ready to take any questions.

Now. Okay, thank you, Santosh. I appreciate it. One of the things that I just want to remind everyone of, I know you're kind of like, well, what are the solutions for when we reopen? And one of the things that I think is really critical, and I think you would agree after hearing her, is that you're not open right now and you have capability and time to look at some of these things in your practice to see how your insurances are occurring. Many of us, I think, leave it up to our staff to just do what they normally do and you're assuming it's all being done correctly. And, and at the end of the day there's valuable dollars that you're losing. So I think in the new world you're going to have an opportunity to look at this a little differently. So the first question we have Santosh is can I change from NPI1 to.

NPI2?

Well you have to have an NPI type 1. You don't have to change that. But in if you are an incorporated entity, you have an incorporation established, then you definitely need to file for an NPI type too. Now I'm not sure how you have filed your credentialing paperwork. You may have to go ahead and individually call each insurance company and let them know that you have been billing under your NPI type 1. If you want to start billing under your NPI type 2, is there any additional paperwork required or just a letter will suffice? I believe Delta will ask you to send out an application because it will want to credential the entity itself. But best option is to call the insurance company and determine the best.

Answer. Okay, next question. Can you be clear on third party insurances did not understand is it the same as being out of network? That was early on in the presentation, about halfway through and perhaps I don't know if Dr. Patwa got her answer from that, but why don't you answer it just in.

Case. Okay.

Being in network with an insurance through a third party does not mean you are out of network, just that your participation with a particular insurance is an indirect participation. So let me explain. Most of the time in the past providers were directly signing paperwork with Aetna to become an in network participating provider with Aetna. But now I see more and more. Furthermore, Aetna is not willing to negotiate their fee schedules because of which providers are now considering using third party networks. Connection Dental, on the other hand has listed Aetna as one of its rental networks and it falls under its subsidiary. So rather than directly credentialing with ecna, a provider has the option to become in network with Connection Dental and start seeing ECMA patients with the Connection Dental P schedule and get reimbursed at the Connection Dental P schedule rates. A lot of times providers ask me so if I am going to credential.

With Connection Dental and I receive an Etna patient, should I be billing or should I be billing connection? No, your billing will be as usual. You will still be billing Aetna. The insurance companies on their end have updated their records and are well aware that this provider is now in network with Etna utilizing the connection debt to fee schedule. So all claims will be processed at that fee schedule. So from your billing front end there is no changes on how you bill but on your REIMBURSEMENT end, the only change will be rather than getting reimbursed from Aetna using Aetna fee schedule, you will be reimbursed with connection fee schedule. I hope I was able to answer your.

Question. Okay, next question.

Are there any tips that you can give regarding addressing any changes that we need to know regarding reopening in regards to billing?

So.

As of now the only thing that I have heard is providers are getting very anxious and they've heard information that insurance companies are not processing claims with regards to pro fees and any non emergency treatment during this lockdown time. But I just went ahead and reviewed some of my provider final reimbursements and I see that providers are getting paid.

On their EOBs even for crowns and pro.

Fees. And what about PPE? Is there any particular code to use for PPE at this.

Time? No, none of the insurance companies, neither ADA has set out any code regarding ppe. But if you want to really increase your reimbursement, go ahead and negotiate that fee schedule and take care of it in an indirect.

Manner. And would you this is a gene question. Would you be allowed to Bill PPE under 9999? Probably won't be covered, but you could bill it I suppose if you wanted it for the.

Patient. Well, it's a good strategy and you can try billing under D999 and put a narrative in the claim remarks and let them know that you're charging this additional $30 for all the extra work that you're doing for screening the patient and for the M95 mask and for all the additional sterilization that you're using. If you are lucky, you may get paid. And if ADA sets out a new guideline, all your claims may be reprocessed even after them being denied. You may be lucky to get payment later on. So go ahead and file your claim with that D999 and it doesn't hurt to bill it with.

That. Okay, next question. How do I know? How do I know? I signed up under an umbrella network. My doctor does not have accurate.

Paperwork. Okay, my suggestion to you is start a spreadsheet and start calling all the insurances.

And see. Find out who's your area network representative and ask him is your provider in network or out of network? They usually ask you for your office tax ID or the doctor's Social Security if he's a sole proprietor and the MPI number and your office address. With that you should be able to look. They will be able to locate if Your provider is in or out of.

Network. Okay, next question is from Andrea. Our dentamax fee schedule has not been increased since we started with them in 2011. We have been told by Dentamax that they evaluate their fee schedule annually and will send us a new schedule if there is an update. We have never received an update other than the new CDT code. Any recommendation for getting denim max fee schedule.

Increased? If your area representative is saying that they evaluating the dentum fee schedules on an annual basis, then that's their policy. The representative cannot pend the policy in any which manner. But we have seen in the past that they have been acknowledging a request. In the last one year dentamax has been saying this and therefore we have not been credentialing our providers with Dentamax because the fee schedules that they are offering is not as good as in comparison with collection or Carrington.

Plans.

So if I'm understanding you correctly and just paraphrasing for Andrea, are you saying that there's no recourse she has right now even though they have not increased her fee since.

2000? That's.

Correct. Okay, so in Andrea's case she would then do what your recommendation was, which would be to look at getting out of Dentamax but making sure that she's with one of those umbrella plans so she could get a higher rate. Is that.

Right? Yes. So one new addition I've seen is, I'm not sure which one, but Connection Dental is I believe listing dentamax as one of its new umbrella networks under it. But you may want to call for that list again. I remember seeing that list about three or four days ago. Yet if, if she is trying to drop dentamax, she needs to think twice because Dentamax has a group of almost 35 or 40 insurances listed under itself. You may get dropped out of all of those insurances. So think twice before you take that.

Decision. Great, great. Next question. Miriam, thank you for your information. Is there a possibility I can watch this video again and PowerPoint presentation? Yes, Miriam, I am recording it. And for all those that attended, I will be sending you the recording with these slides now. Next question. If you have indirectly in. If you are indirectly in network for a company, would it be correct to tell patients that you are in network or legally? Do you need to explain that you are a third party.

Provider?

I don't think patients are going to go to that depth to ask whether you're illegally or in network through direct participation or indirect participation. Patients just want to know the bottom Line, are you in network or not? And yes, you can tell them that you are in network participating.

Provider. Okay, thank you. Next question. With that example, if you are credentialed directly with Aetna and you are not credentialed with Connection Dental as well, which fee schedule will you be reimbursed when seeing an Aetna.

Patient? Can you repeat that question.

Jean.

With that example, if you are credentialed directly with Aetna and you are not credentialed with Connection Dental, let me rephrase. If you are credentialed directly with Aetna and you are credentialed with Connection Dental as well, which fee schedule will be reimbursed when seeing Aetna.

Patients?

Always, the rule is that if you are directly in network with any insurance, whether it is Aetna or Cigna or principal, if you sign a direct contact with that particular insurance, you will follow that particular insurance's fee schedule unless you did not sign any contract with that insurance. That's the only time you will use the umbrella network fee schedule, which in this case was connection dental.

Okay. Someone said that their screen was black and there was no video. I did not get that from any other person. I don't know if that was their own technology error. I saw on ADA that they suggested D1999 for.

PPE.

Well, I'm not aware of that code. I can review that and get back to.

You. Okay, great. And then will insurance companies reimburse dentists for ppe? If so, are there already established codes? I think we already answered that.

So.

I think we've answered all. But there's a couple coming through right now.

FYI, Ameritas Contrast added a clause about two years ago that allows them to use any fee schedule that we are contracted with. So now we are forced to take Denimax fee schedule for all Ameritas patients. Do you know that to be.

True? If you are forced to take Dentamax fee schedule for all Ameritas patients, call the Dentamax representative and ask him to send you an opt out form. Dentamax has about four or five opt out forms. One is for Meritus, the other one is for Principal and it has one for Standard Life, I believe, and one for Status Network. Go ahead and call for that opt out form, send it out to Dentamax within three months. You should be able to see that you're out of network from the dentamax fee schedule and you should be able to be picked up by either Connection Dental. If you are in network with Connexion or with the Aetna fees. Please evaluate your fees and your top codes on a spreadsheet before you make that.

Decision. Okay. If patients ask if we take their insurance and we are not in network, do we need to tell them specifically that we are out of network? Or can we say we take all PPO insurances in including their.

Insurance?

Dental offices verify insurance for patient As a courtesy, the patient should know if a provider is in or out of network. Because the.

Insurance rules have been changing so widely in the recent times, a lot of providers are not sure if if they are in network or out of. I'll give you a simple example. CIGNA has two networks, which is CIGNA DPPO and CIGNA DPPO Network Advantage Plan. One of them has a higher fee schedule. So if you are in network with the CPA DPPO plan, which I believe has a higher fee schedule than the Advantage plan, then and you're utilizing the DPPO fee schedule, then you're going to be out of network with the CIGNA Advantage plan. But if you are in network with Cigna Advantage Plan, then you are in network with both. So if your office is using a very high fee schedule with CIGNA and you think you're in network, you tell your patient with ignorance that you are in network. He's not going to hold you accountable when the EOB comes in. He is definitely going to hold you accountable when the EOB comes in. @ that point you will be liable to give an explanation. But you can only say as best as.

You know.

Okay? And then we've got a chat here. Let me check that.

And let's see here. I've been told by insurance companies that I'm in network but feel schedule is through blank company. Which of the two is the umbrella? I don't know if you'll know that. It says I've been told by insurance companies that I'm in network, but the fee schedule is through, let's say a different company. Which of the two is the umbrella plan for him then.

Or her? Okay. Your umbrella will be the plan.

So I give you an example. When you call the insurance company for a principal patient, insurance is going to tell you the fee schedule that you follow is dentamax. So your umbrella plan will.

Be Dentamax.

Okay, I think that's it. Well, thank you so much, Santosh. I appreciate your time and you were very helpful. We had some lot of great questions. I'm going to go ahead and end the recording now. And we will get that out to anyone that was on the line. And once again, thank you. Thank you, attendees. We hope you can attend our webinars the rest of the week. They're going to be great guests as well. Thank you so much.

Take care. Thank you.

Bye bye. Bye. Bye.

Sa.