Navigating the PPO Landscape with Nick Partridge

Hey, dental associates and new practice owners. Welcome to the Associates on Fire podcast, powered by Practice cfo. This is the podcast that teaches you what you never learned in dental school, the financial side of dentistry. We cover topics from planning for ownership, buying a practice, to student loans, taxes, and all things financial for the hungry to learn. Dental Associate. So let's light it up.

Welcome, everybody, to another episode of the Associates on Fire press program. We have today, Nick Partridge with us, founder of Five Lakes Dental Solutions. And what they provide is support on credentialing and negotiating your PPO contracts. This is an incredibly relevant topic because most of you who are listening to the Associates on Fire program eventually would like to own a practice, either as a partnership or maybe as a group of dentists or of course, as a private practice owner. And if you do, you're probably going to have to confront at some level the PPO issue or challenge because it's so prevalent, particularly in different sides of the country. I'm down here in Southern California and the PPO landscape is thick down here, very, very heavy. And so every doctor that we sort of represent who buys a practice down here, we. We have to address what are we doing about the PPOs? What if they have Delta Premier? Nick, I'd love to talk quickly about Delta Premier as well. Huge subject for dentists buying a practice and even for practice valuations. This is just such a relevant topic. There's been a significant increase in PPOs over the past 10 to 20 years, and a lot of times I'm finding dentists are using the PPOs in order to get butts in the chair. It's. It's the way that they tend to market themselves and it's a more expensive way of marketing. But if you can manage those PPOs effectively, I. E. This is why we have Nick on the podcast today, that maybe it doesn't have to be as expensive of a way to get those butts in the chair. Also, it's important that we understand how to work with the PPOs and that there is a sort of massaging of those contracts or interaction with those PPO providers that can help give you a little bit more advantage than just sort of accepting a take it or leave it option. So, really excited to have you on the program today, Nick. I'd love it if you would just tell us your story real quick. How and when did you get into helping dentists get credentialed and negotiate their PPO contracts? Tell us a little bit about your history.

Yeah, sure. Thank you so much for having me. I'm really, really excited to be on here today. And like you said, insurance is kind of a growing animal in the practice. And so it's really important to address it, whether you are fee for service or selectively participating or all in, you know, so. And one of the things I really am excited about is sharing this conversation with you and getting your perspectives as well, because I think as we've talked, we both at heart have that planning bias as, as the foundation of a good relationship and helping dentists achieve their goals. And so, so anyway, so thanks for having me. I happened into this now 11 years ago almost, I was involved in another dental startup and I was spending my time trying to get dentists to join a network that we were building. And at the same time, we were trying to grow the number of members that we would serve with employers administering their benefits. So we'd set up like a little tpa. And so the question I was always concerned about in going to recruit doctors into our network was how many members am I going to turn into patients in my office? Because it was a little bit of the chicken and the egg. You know, it's, can we attract dentists into our network without members? And then can we attract employers to administer their plan through us if we didn't have a network? You know, so, so it's, we were debating about what, you know, what was the best course of action. So we ended up splitting our time and, and in my time doing that, not a single dentist ever asked me that question. So ultimately we closed the business down. But I learned from that. And I said, man, I've got to help these dentists understand more about insurance, because as we saw it at the time 11 years ago, I thought it was only going to continue to become more and more important and more relevant in their practices. And so, so that's how we got started. So we've been doing it now for quite some time, and we've got clients in all 50 states. And so we're very, we're very blessed to, to be in this position where insurance has gotten more important and it's gotten, you know, the insurance companies are a little bit more aggressive about their, their approaches. And so helping dentists figure out how to use insurance, if it makes sense to achieve their practice goals is what we're really all about.

Cool. So, so much of this program is all about education, and a lot of the people who will be listening will be really still in dental school, in fact. And I know insurance is a concept that I think most of us Understand. But let's start from ground zero for a sec. Explain what it means to be in network with the PPOs. Maybe give us some examples of the big ones in the space of dental. And what does it mean to be out of network as well? Let's just start with some basic definitions here.

Yeah, so, great point. You know, I really want to make sure that we, we provide a lot of education here today. So. So please, you know, this is good to start with the base. So insurance is a benefit, right? So employers, in an effort to attract and retain talent, have over time started offering benefits. And so the dental benefit itself can be structured many different ways. Okay. It can be structured as where the employer would pay for some or all of the dental care they can set up. They can participate or sponsor an hmo. There's all kinds of different benefit plans and benefit structures. But at its core, the idea is this, that the employer would offer a benefit to their employee which would help them do two things. Number one, encourage them to go to the dentist to get regular care. And number two is offset or lower the cost of the treatment. Right? And dental insurance is really effective at doing that. So an employee has, with a dental benefit is two and a half times more likely to visit the dentist. So the, the act of offering a dental plan to an employee and their families really works well. It gets them into the dentist and it does help offset the cost of care. So from the starting point, I know dentists don't like insurance, right? But really, no one likes insurance. If you think about it, I mean, homeowners insurance, car insurance, renters insurance, life insurance, dental insurance, health insurance, it's never good enough, right? It's never good enough. It never covers enough.

So, so if we go into the conversation saying nobody likes dental insurance, you have to understand that it does actually work. It puts patients in chairs every single day all across the country. Now, there are different ways that these benefits benefit plans are structured. Okay? So the most common is called a ppo, a preferred provider organization. What that means is that the dental plan itself is structured. So generally speaking, the plan will offer coverage for preventive care, for basic care, for major care. Optionally, you can get orthodontic care covered. There's deductibles and maximums involved. So there's different plan structures, right? And so a PPO works where when you go to a specific provider who's been credentialed in a network, then they're called a preferred provider. And that preferred provider, in exchange for the opportunity to get access to patients has accepted a request reduced fee as payment in full. So if your cleaning fee is $125, then you might sign up with an insurance to be in network. Once you're credentialed and you meet their criteria, then you might accept $100, let's say as an example, as payment in full, okay? And then that's it. You cannot collect the balance from the patient. Now when you see the patient, then you're going to record that visit with a claim and you're going to send that claim into the dental insurance company for reimbursement. So you're going to record the transaction and the care with the claim. They're going to send the claim into the insurance company, they're going to send you $100 and then that's it. Right. So when you're in network, you're accepting the reduced rate because there are incentives for patients to come and see you as an in network provider. It can be done a number of different ways. Number one is just apples to apples. It's going to be cheaper. So if I have two dentists right next door to each other and I have a, let's say one of the largest dental insurance companies is MetLife, so Delta is the biggest, followed by MetLife. And then usually you have like Aetna, Guardian, United Healthcare, United Concordia, they're kind of in there in the next ring. Cigna is in that ring as well. So if I'm, let's say I have a MetLife dental insurance plan, then I'm looking at two dental offices side by side. One's in network, one of the, where the provider is in network and where the provider's out of network. It's just cheaper for me to go to the in network provider. Right? So because the way that most PPOs are structured is they pay a percentage of different types of treatment. So you're going to pay 100%. Most insurance plans will pay 100% for preventive care. So your cleanings, your X rays, your exams, they'll pay 80% for what they consider basic or Class 2 procedures, which would be fillings, simple extractions, things like that. They're going to pay 50% for major procedures which would be considered like crowns, bridges, dentures thing, you know. So.

When you are in a position where you have a treatment that requires an out of pocket payment, then it's cheaper for you to go in network. So that's the inherent advantage of being in a network provider is people are more apt to go there. They've Also modified their approaches where now they will structure the benefit to be richer. If you go in network, Right. So if you go in network, maybe your maximum, the amount that the insurance company will contribute will be higher, maybe the coinsurance percentage is higher. So if you go out of network, they're going to pay less. Right. So there's different incentives that the insurance companies can employ to steer patients who are their members. Right. So they're dental insurance members into your practice just because of the way the plan's structured. So does that help give a little bit of a background into the difference between network and out of network?

It does. And let me make a couple comments, maybe into some follow up questions. One common term if dental students or early stage dentists don't know about is called your ucr, which, correct me if I'm wrong, Nick, stands for your usual and customary rate.

I think it's usual, customary and reasonable.

Oh, okay.

So the, I don't know how that became the terminology. It's what you charge at your office, right? It's your office rate.

Yep. It's your menu, right. It's, it's your price per procedure stated on. If you had, you know, like a restaurant menu book, that's what your price would be. That's your stated rate. But the insurance companies sort of say, hey, we'll filter people to you through our network program, but you're going to accept a lower rate.

Now on if they're out of network, they're the doctor is able to still get their full ucr, is that correct? It's just the insurance company is, is covering a less of that payment for the insured or for the patient.

What happens is when you're an out of network provider, because being in network and out of network is specific to a provider. Right. So it's not necessarily the practice. Right. You can go into a practice where there's three doctors and two are credentialed in network and one is not. Right. So it's specific to the provider. So the provider, you see when they're out of network, there's a couple things that will happen. Number one is when you file the claim, when the, when the office files the claim or if they ask you to file the claim, then the insurance company doesn't have a contracted rate. And so if you're going to submit a claim, let's say, you know, just for example sake here you submit a claim for a cleaning for a million dollars. Well, the insurance company is not going to pay some percentage of a million dollars. Right. They have what they call the. Their ucr. So the insurance companies you see are specific to that area, and it's based on what other dentists in the area are charging. So they, they define usual, customary, reasonable fees for that area, and they say, okay, well, look, I see that you filed that claim for $1 million for the cleaning. UCR in this area is 110. So we're going to reimburse at whatever percentage per this plan based on the rate of 110. So if your office fee is still 125 and now the insurance company's agreed to pay you 110, you can then go collect the $15 difference from the patient to get your full fee.

Got it. So if they're out of network, you can still collect your full fee. Correct. Now, in that example, 125 down to 110. Here's what I'm seeing and hearing. Let's just do a standard Crown, and your UCR here in San Diego might be 13 or $1,400 for a crown. Delta Premier, which, as you mentioned is Delta, I'm sorry, is the largest PPO provider. And here in Southern California, that's the biggest name hands down. I think they're reimbursing under $600 for an in network reimbursement. Does that sound about right?

That sounds a little low, but. But you're not far off, I would think. Yeah, I mean, so I think in a lot of parts of the country, it's, you know, 685, 750 somewhere in that range.

Yeah.

Yeah.

So if you look at that write down, you're essentially writing off the term write off. There's another definition. The write off is for many dentists on who are accepting Delta. PPO is over 50%.

And yet the cost structure, and I've said this in almost all of my podcasts, I feel like the cost structure to deliver that crown is still the same. You're paying the same thing to your staff, your same supply costs. Maybe you decide to go cheaper on your supplies and labs because you're not getting reimbursed as much, perhaps. But by and large, everything to deliver that treatment, that restorative work to the patient is the same. And if your profits on. If somebody had paid your UCR fourteen hundred dollars, let's say that your profits, after all of your direct and indirect costs, Indirect costs are going to be you, your.

Employee time, your front office time, your rent, the space cost, all of that stuff. Let's say your profit ends up being $600 on that crown. Well, if, or let's say, I don't know, it's $800 and your UCR is $1,300. So you got $500 of overhead there. Well, now if you're getting paid $600, your overhead's still $500. Your profit is $100. So you went from $800 of profit down to $100 in profit. And that is a very, very limiting factor for dentists in sort of achieving the financial success that they're hoping for, particularly when they come out of school with 6, $700,000 of student loans and they live in a place where your average house costs a million dollars, like California. And you know, and you know, all these other things demanding for their, demanding their dollar, it's hard to make ends meet. So now we, now we can really get into some of the meat of, I think our conversation is as somebody approaches the purchase of a practice. And let's say that this practice has Delta, we'll even say it has Delta Premier. So maybe we can talk not just about dealing with the, with the PPOs, but let's also say there's that added layer of Delta Premier, which. Let me go ahead and try and explain what the problem is, Nick, and you can add to that. But a buyer is buying the assets of a seller. The buyer establishes their own corporation. The seller has their own corporation, typically. And you're not buying their stock, you're simply buying their dental supply, I'm sorry, their dental chairs, their X ray machine, and anything in the purchase price less that sort of hard equipment, tangible equipment, is called an intangible equipment known as, as goodwill. And so let's say you buy this practice for a million bucks. 200,000 goes to equipment, 800,000 goes to goodwill. You move that into your corporation as assets on your, what's called, balance sheet in your corporation. And now you have a brand new entity. It's a brand new tax id. You have your own national provider id, your own npi. These are the numbers that go on a claim submitted to a PPO for reimbursement. Well, as soon as any of those change, from what I understand, if the tax ID changes on a claim, if the, if the NPI changes, and I think even if the address changes, tell me if I'm wrong. But Delta will not honor that Premier rate which is going to be much higher for a crown, like eleven hundred dollars for a crown as opposed to $600 for a crown. And now you lose that. So the seller who's been getting $1,100 a crown and all. Delta Premier Crowns is not able to give you that same rate reimbursement rate. You're going to now take $600 per crown. And let's say this is a 30% Delta Premier practice that has to be considered in the cash flow effect and I believe the valuation price, because valuations are always a function of cash flow to the buyer, not necessarily what the historical cash flow was. And that's out of your hands. So you're going to see a lower cash flow, a lower take home profit because you're not going to get Delta the Delta Premier rates. All right, Nick, to audit me, did I explain the Delta Premier problem accurately?

Yeah, you did a nice job. That was good. You know, I think the bottom line is that if you are looking to acquire practice, you have to understand what you're buying.

Right.

The due diligence aspect is really important because Delta Premier is a stratified network. Right. So basically what happens is there are two different networks that you can join and one is no longer available. Right. And they're looking for opportunities to continue to restrict the number of people that are paid off of that old legacy fee schedule, that it's been replaced by a new network which is much lower reimbursing. And that's not really unique to Delta. That's a common strategy that many of the insurance companies employ. And you're continuing to find scenarios whereby any type of ownership change or provider change in the office is going to put you in a position where you cannot replicate the previous status, what we call contracting status, which is how doctors are contracted in networks. So it's very problematic and it's really important that when you buy a practice you, you get somebody like Wes who will guide you through these difficult decisions because it does affect potential future cash flow, it does affect the value, it should therefore affect the valuation. And so, so yes, absolutely. And it's, it's not, like I said, limited to Delta and it's, I would think it's going to be increasingly common because insurance companies are looking for ways to reduce their costs.

And you would think that it would be easy to quantify what the reduction in collections would be by not being able to accept Delta or get Delta the Delta Premier fee schedule. But it's actually never been easy for us. We've represented hundreds and hundreds of doctors buying practices and we always go into the practice and we ask the doctor in the front office person and say what percentage of your collections are coming from Delta Premiere. Now, you could get really sort of granular about this and look at all the treatments and what the Delta Premier fee schedule is for that treatment. Usually what we do is we try to sort of take a relatively efficient, reasonable approach to find out, okay, it's 20% of this doctor's collections are Delta Premier. And we're finding that it's usually around 30 to 40% of a reduction on that.

Let's say 25% of collections are Delta Premier. So you take 25% of their collections. Let's say their collections are a million dollars, $250,000 are coming in from Delta Premier. Well, you need to go take a 35 to 40% reduction on that $250,000. Let's say that's $100,000. And so now you know that you're going to get $900,000 in collections per year where this doctor was collecting a million dollars, and you have the same amount of overhead. So if the profit was, let's say, $350,000 on that practice, your profit is now going to be $250,000 and you're going to have debt that that doctor probably doesn't have at this point in time. That's why running a prospective cash flow to make sure this is going to work is, is really important. And that if it doesn't work, you go back to the seller and say, seller, you're a Delta Premier practice. The prospectus doesn't even mention that. And the valuation price doesn't mention anything about this reduction in cash flow to the buyer that any buyer is going to get. Any buyer. It's not just me. It's going to be the next buyer and the next buyer and the next buyer, if you pass up on me. And so I believe we need to reduce the valuation to be from, you know, let's say it's a $800,000 valuation down to, who knows, 725, $750,000. Save some money there. But that cash flow analysis is just so important for buyers to make sure they're not stepping into a booby trap in a way and unexpectedly seeing that, that dramatic reduction. So there's no way. Just confirm, Nick. There's no way to assign an contract of a seller to a buyer. It's always sort of a new set of contracted rates. Is that right? Yeah.

So it gets really interesting. I mean, I love this game, you know, the game of business as it relates to these two parties, provider and payer. No, it depends. So, you know, the insurance company do what's in their best interest. Right. So, like I said, so what's interesting to me is that Delta did this a few years ago, and it's still novel in the marketplace. There's still a lot of people who buy practices, unaware that this is, this is happening. And what's happening now is insurance companies watch each other, just like dentists watch each other, to find out what are they doing to market, what's their prices, you know, how are they, you know, how are they on social media, what's their office look like? You know, they're watching each other, too, and they're finding out what works. And insurance companies are finding that what Delta did was really smart because historically speaking, many insurance companies have reduced their rates. They've. They've come out and they said, hey, look, I'm sorry, but we can't support this rate. We need to reduce your rate. And so that draws a lot of public attention and a lot of animosity. And in fact, Aetna is doing that right now, and it's a big disaster for them because it's a big PR problem. What Delta did by doing this was very, very quietly shut off this network over time, which creates a lot less ripple effects. They can say that, hey, they've never lowered rates, right? They haven't lowered rates. They just. You're just not able to get on the high rates like, like you used to be. Right. So I think it's a really good move by Delta, if that's your goal, is to reduce the. The rates. And I think other insurance companies, like I said, are now doing this too. So it's not just Delta, it's other, other companies. And so you need to go in and do due diligence. And that's one of the things we do.

As part of this, is we get in the weeds and find out exactly what the cost differential is going to be so that we can anticipate what that looks like. Because if you're looking at $100,000, not only is that a hit to the bottom line at the end of the year, but there's some seasonality in dentistry, and you could be talking about the difference of $10,000 a month in cash flow, you know, so what does that look like?

So if we're representing a buyer and we need to figure out, we need, we need to zero in on the effect of the loss of the Delta Premier fee schedule. That's something that you can go in, pull up all, you know, the fee schedules within their practice management software. You look at the contracts. And you can, you can identify is it a hundred thousand dollars or is it $200,000 or is it only $25,000?

Yeah. And what we do is we do it like you said, we get into the weeds. I mean, we look at it by, on a code by code basis, see what you've performed over the past 12 months and then how that manifests against the fee schedule difference to figure out what the net difference is.

That could be really helpful. You and I are going to become good friends, I think. Let's jump into now. Let's say I'm a dentist and I found a practice and I put a letter of intent in and a letter of intent for you associates, if you're not familiar with that term, that is the document that attorneys will often draft up. Or brokers have a template that you sign and that the seller signs, agreeing on a given price and establishing certain due dates around the completion of due diligence and a target close date on the practice. It's like putting on the engagement ring. It's not really legally binding in most states, but it's saying, hey, I'm committed to you, you're committed to me. Let's stop going out to bars, let's not be on the open market now and let's see if this engagement leads to, you know, consummating into a marriage. And.

During that time, you got a lot going on. You're working with your bank about getting lending. You're seeing if you're qualified for lending. You've got the landlord you're working through to make sure that the lease is assignable, assuming that the seller doesn't own the building. And then one of the other big things, of course, is the due diligence. But one of the other big things is you need to get your corporation in place. And for most of you, virtually all of you, you're going to be set up as either a professional corporation or an llc, a limited liability company. And in some states it's a PA professional association, I think a professional. Can you remember what PA stands for? There's only a few with those, the states that allow you to do an LLC, please do it as an LLC. States like California, LLCs are not allowed for dentists. So you set yourself up as a professional corporation, but to the tax agencies, you file as what's called an S corporation, regardless how you're structured legally at the state level. So at the end of it, from a tax standpoint, you're all set up the exact same way, pretty much as An S corporation, a small business corporation. And, and when you do that, you then need to get credentialed with the insurance companies. Now, I know it's by provider, as you said, Nick, but doesn't the tax ID need to go somewhere in the credentialing paperwork?

Yeah, so the owner will. If it's like a one doctor location, you do both at the same time. You register the business with the provider.

Got it. Okay. So you're registering the business, which is the tax ID of the corporation, and then, then you're also registering the individual provider with the, with, with the, with the PPO as well. Correct?

Correct. Right, yeah. Which is by the, with the npi. Yes, the.

Now tell me, tell me about that sequence of events, when they should start and what that, you know, what that looks like.

So the, it's kind of interesting because like you said, it's really two efforts. There's two things going on. Number one is there's a lot of effort towards making the transaction work, right? It's having conversations with you about getting the tax ID set up and getting the books set up and making sure the valuation's right and the negotiations are moving and doing some due diligence and, you know, and the landlord and all that stuff. But there's not a lot of thought to like what happens from day one forward. Right. And that's really where we come in, is we want to come in and say, listen, we're all about a helping you on the due diligence so that you can get the valuation right and you understand what you're, what you're getting into and what's replicable and what's not, but really about what your practice is going to look like moving forward. So the reason that people pay so much attention to insurance is because it's the lion's share of revenue in a practice, whether you're in network or not. 80% of Americans have a dental benefit, so you're getting a majority of your revenue from, from insurance. And that's why you have to take it really seriously and play the, play that game very smart. So we're really trying to get you to focus and say, hey, look, I know that you're busy over here trying to take care of stuff for this transaction, but let's start thinking about what your practice is going to look like because it takes time. If you're going to start today with an application into Delta Dental of California, you're not going to be in network for 90 days.

So you have to start the effort towards what you're going to do with insurance really early on, because it takes time for the insurance companies to process your information, get you set up in their systems, and then you're off to the races. But what you really want to do is you want to also think about what am I buying, right? Because I have seen people make really unusual decisions about being in network. Right. I worked at the startup, and she wanted to be a network for her aunt and uncle. And so we sat down, we did an assessment of her practice. We got all the fee schedules from all the different insurance companies. We mocked up forecasts of what her practice was going to look like after one year and what these fee schedules would look like to her bottom line. And we said, don't do that plan. Just, I tell you what, just offer her like 50% off. Just have her come in and just give her 50% off. And she's like, no, I really want to be in Network Plus. If I do that, then, you know, we'll get other patients from that plan. Okay, fine, right. So a year goes by and we sit down again for our annual review and we go, hey, look, you know, this is, you know what this meant to you. And she's like, oh, man, I should have just given her 50% off. You know, so when you're buying. My point in saying that story is only that when you buy a practice, you don't know why the doctor made the decisions that they did go and network. It could have been an office manager who made a decision six years ago. They got faxed a fee schedule, she's no longer there. You know, so don't just assume that whatever networks that this office is in that you need to be in those networks, or those are the right networks or those are the right fee schedules for you.

So in terms of timing, is there any reason to. Not when you come out as an associate. And let's say, let's say you're being paid as an independent contractor, and let's say you're being paid $175,000 as an independent contractor at that point, right around 175,000 to 200,000, we will tell doctors to set up their own corporation. But even if they don't set up their own corporation, they can still just act as a sole proprietor, which is the default entity structure. If they don't set up a corporation to receive their independent contractor pay as an associate, why not just get credentialed with the sort of the big ones, maybe at least delta, just right away, you haven't even found a practice yet. But let's say you set up your corporation, you have a tax id, you have an npi. Is there a reason why somebody couldn't and are there annual costs that they have to pay to maintain that such that when they, so that when they buy a practice it's already in place and on day one they can be billing under Delta. Delta. Is that okay?

Yeah, really good question. So just to be clear, when you're an associate, generally you don't have a say on this. So if you're going to work as an associate for a practice, they're going to tell you that these are the networks that we're going to participate in because they want to create a certain experience for their member, for their patients and they have a certain, maybe a strategy around what they're going to do. So when you join up as an associate, they're going to usually they should take care of the credentialing for you as well. So they're going to credential you into the plans to mirror whatever strategy they're trying to employ. When you are going to then start your own practice, you will have been in the system, right? So you'll have been in MetLife system or Delta system. So the paperwork requirement is a little bit different except you're going to also be registering your business at that time. So it's, it's again a little bit of a difficult process because yes, if you were to move from one associateship to another, then the paperwork is less and the timing is less. But if you're going to move from an associateship to an owner, you're also, while you're already credentialed, your business has not yet been and you're at a new treating location potentially. And so there's a little bit of complexity there.

And when you say business, that's, that's the corporation you're talking about. The corporation's tax ID has not been credentialed even though you as an individual are credentialed with those insurance company through the practice that you were associating with. So when you go to buy a practice, you only have to do sort of half of the credentialing work. And is that time to do that less than credentialing, both you as a provider and the corporation?

Yeah, it depends. So insurance companies require that you re credential usually every three years. So they're going to validate that you still have your dental license, that you haven't been reported to the board, that you you know, they do criminal background check and they do those every three years. So it depends on when you're, where you're at with that cycle. But yes, if you're, let's say that you get credentialed as an associate with Delta and then you move to another location and you associate there or you start your own practice, your credentials are already as a provider within three years are going to be valid. So it's going to be a little bit different, a little bit less time. But then again, they have to go credential the business. And we run into this with Delta specifically you have to have an address that is post office verified. So otherwise their application will not go through. So a lot of times when you're working with new construction, that's not the case yet. Right. So we have to wait until the landlord or the, the builder actually registers your address with the post office, it gets loaded into their system and then Delta can verify it before they'll continue with your application. So there's all kinds of weird nuances to this. And if you work with, you know, my advice would be to work with somebody to, to, to guide you through this because there are, every insurance company does it a little bit differently and every state has different rules as well and different networks that are important because.

Here'S what's happened, here's what happens when it's not done early enough is they close on the practice and, and they are often the buyer and seller agree if the relationship is a certain way to continue to bill under the seller. Now if the seller is there as an associate, they're working back, then they might bill as under their, some cases they'll even bill under their own corporation and then sort of route the money back to the buyer. And it gets sort of, it gets a little bit tricky with the cash flow management. And at the end of the year, as you know, the insurance companies issue 1099ks or these, these reports showing how much they paid a given corporation in insurance. And if the money was deposited into a different, into the buyer's corporation, but those 1099 are issued to the seller's corporation. It can get a little tricky there from a tax reporting standpoint.

And, but sometimes the seller just doesn't feel comfortable at all doing that. They feel like, well, this isn't, this isn't right because I'm not doing the treatment myself. I'm, I, I'm out of the practice and you need to figure it out and bill under your own corporation and npi. But then the then the buyer is thinking, well, I'm not going to have any cash coming in for 90 days or I'm going to have very little cash coming in for 90 days because this is a heavy PPO practice and I'm not credentialed with any of these companies. Usually what I'll say is that's why you get the working capital from the bank, usually to the tune of 50 to $100,000. So you have some cash to get you through the dry period until suddenly.

The dam breaks and all the PPO money starts coming in. Once you're credentialed at that point, what's some advice you have, or as you work with dentists, how to address those first one to three months when they're not credentialed at the point of close and the seller is out of there, or maybe even the seller is staying in a little bit. What are some of the solutions to address that, that problem, that cash, that cash flow problem?

That's such a great question, because in reality there's no good answer. The insurance companies don't move at the pace of business. Okay? So anyone who tells you that this is going to be seamless and smooth is not being straight with you about what's happening, because it's not easy. What I will tell you is while you're taking over, and if you're not yet credentialed in network, it's okay because you will still receive money from the insurance company. Just because you're out of network, as we talked about at the very beginning, doesn't mean you won't get paid. Right. In fact, in some cases you'll be paid more because their UCR might be higher and in many cases is higher than the contracted rates.

CR is higher than the contracted rates.

No, the insurance company's ucr. So we gave the example of if your cleaning fee is 125, the insurance UCR is maybe 110, but their contracted rate's 100. Right. So in many cases you'll do better. You can also discount if you tell your patients, hey, look, I just took over. I'm excited. The last thing I want to do is make you upset. Right? Because I'm not in network yet. I'll honor the in network fee. Right. And so you can discount down to make it equal in many cases, equal for the patient in terms of what they have to pay out of pocket to what it would have been if you're in network. Okay, so there are things you can do to work through this, for many of the cases, what you also want to do, because you want to take this opportunity when you buy a practice, it's an opportunity. You know, when you register for like health insurance, they call these things qualifying events, right? You can't just join your health insurance plan at any time. You have to wait for a qualifying event. This is a qualifying event. And insurance companies work like the cable companies, right? If I call up and I say, hey, I would like to have my rate reduced, they'll say, no, sir, we're not able to help you. But if I'm a new customer, they got all kinds of deals, they got all kinds of specials because they want you in the network. So you can't waste this opportunity of buying a practice or starting a practice, because that's the feast. Whatever you negotiate and get put in place is the fee schedule that you have as the baseline forevermore, right? So every time you go and negotiate, your increase is going to be based off of where you're at. So if you start really low because you're in a hurry, you're going to make, you're going to, you're going to cost yourself a lot of money throughout the rest of your career. So it's worth it to take 30, 60, 90 days and do it right and then build the practice going forward.

Can we talk about that? I want to dwell on that for a few more minutes. Doing it right? What does that mean? How.

How much variation in the fee schedule that you're negotiating with with that insurance company? How much variation is it? Is it a take it or leave it? Does it depend on the insurance company? And if you can negotiate that higher, a higher reimbursed fee schedule, how do you do that?

Yeah, so I don't, I don't want to intimidate, you know, early stage dentists here or people in dental school who are thinking to myself, I haven't even gotten my license yet, let alone come out and face the insurance companies. But I'll suffice it to say this, there's a lot of things that you need to think about. So the first question is, do you need to be in network? We don't advocate that you just take every insurance company, right? So while 80% of people have a benefit, not everyone is, is in network. And especially today with what's going on with PPE costs and things like that, it's making people reconsider. Because if your capacity to serve is also reduced, then you might be in a position where you don't have to take as Many insurance plans. So, so the first question is, is what are you trying to do? What are your goals? So let's match. Let's think about how we can use insurance to match to get you to where you want to be. So let's. Delta is a good example because they have the two networks. So Cigna has two networks. One pays better than the other. It gives you access to different patients. United Concordia has like six or seven different networks. Some insurance companies will, you know, will work with you to build a custom fee schedule. Others are going to give you a fee schedule that's specific to your area, you know, so you have to go in and you have to look at these different scenarios. One of the other common things that's happened is all the insurance companies have partnered together so that they share each other. So what happens if you join emeritus and you join principal is you get. They share each other, they share their networks. So we always say, don't join. Both join only the one with the higher fee schedule because you know that you'll be shared across to the other one. Right? So you have to look at the sharing opportunities that exist within the insurance companies. So there's lots of different tactics that are available to find out what's the right approach. So when you go and negotiate, you do have many things at your favor, right? So you have, if you're a new practice, I mean, they're going to want you in network, right? Their goal is to have a lower, lower claims costs. And so if they, if you're in network, their claims costs are lower than when you're out of network. So they're going to want to get you in network. So start from there, negotiate. Now, when you negotiate, there's not an infinite pool of dollars that the insurance companies are excited to give you. The insurance companies are going to say, okay, well, look, you know, what codes do you want to work on? Where? And what we do is a real analytical discussion about how to find the right codes that are going to drive the most value. Right? So a lot of times I was having a conversation with the doctor the other day and he says, oh, my hygienists complain about these codes. They complain. We looked, we go, yeah, but you only do those like eight times a year, 20 times a year, right? They're not relevant. So let's really focus on the codes that are going to drive the most value. Let's make sure your office fees are priced right because it's hard to go to the insurance company and say, I'd like to have more money. I'm not being fairly paid. When they're only a few dollars off from what you're currently charging. Right. Because the insurance companies are going to say, well, if you charge $100, I'm not going to make my fee $110, I'm going to make it $80. Because I have to drive. My goal is to give my member a benefit. Right. Some savings. So it depends on. So there's all kinds of things like this. So I don't want to overwhelm you with all the different things that we look at to consider, you know, how to negotiate, what to negotiate, whether to be in network or not. You know, you have to look at the patient base you're buying. You know, how many patients do you have, how many would be at risk of leaving? You know, 85% of people visit in network dentists. So 85% of people with a benefit go in network. So there's certainly a reason to be in network. We just have to make sure that we understand, you know, where you're at with the practice and what your goals are and if it makes sense with all these other tactics.

And it's safe to say that most practices that are selling haven't really looked at their contracts and the.

I guess the, the relationship with the PPOs, what their opportunities are, where they are leaving money on the table. They're just sort of going with how it's been year after year after year after year. And if you're coming in to buy the practice, if there was ever a time to reevaluate, to go back to the whiteboard and say, what is the optimal set of contracts and networks to be in for this practice? As I start, it's going to be on day one. It's going to be at the onset because as you said, that creates the baseline from which any future sort of changes start. And so if you can get that baseline higher, that could have a compounding benefit over many years to come that you're in those specific compounds, contracts and in those networks. So I would. One of the biggest takeaways from this podcast is just make sure you get that configured as optimized as possible on day one. And honestly, I don't think, I don't see how anybody could do that on their own without a company like, like yours, Five Lakes Dental Solutions, to go in and sort of, who understands all that, understands the way these companies think, the way they work and to get that configuration in place.

Yeah, I mean, I agree. I just, you know, it's one of those things where there's, we put out a lot of content. I love what you guys are doing here with associates on fire, you know, all this content that you're putting out to educate, I believe in that as well. We do that. But it is, it changes all the time too, you know, so it's really important that you get somebody to help you with this because it's a, it's an upper battle. I mean, you're fighting companies. MetLife is publicly traded, right. Aetna was just acquired by CBS. UnitedHealthcare is like about the third largest company in the country. You know, so it's just you against, you know, Goliath. Right. And so you've got to really figure out how to do this game, right, because again, it affects such so much of your, your, your revenue.

Couple questions is.

I want to go on to talk about the large group practices or, or the, maybe that maybe the regional practices that have, say, 10, 10 practices and what sort of benefits that scale can give you when you're working with the insurance companies. But before I do is here's a scenario where recently I was helping a doctor. They're buying a practice and they are not credentialed, and yet they're set to close. And about 20% of the practice is Delta Premier. That's the only PPO that this practice has. The rest is fee for service. And so what they decided to do was the seller is still going to work for one day a week for a period of time, about six months. The seller will come in on that one day and they'll do only the Delta Premier patients. The seller will deposit the collections related to that Delta Premier into his own corporation. And then he'll keep his 30% associate pay and remit the 70% back to the buyer. And the buyer deposit that deposits that 70% into her corporation. And it's just an inverse away of paying the seller, who is now an associate, while maintaining the higher Delta Premier fee schedule during those three to four months of getting credentialed. Apparently right now with COVID insurance companies are backed up and is taking longer than, than three months. Is that allowed by the insurance company if they were audited, would that, would they apply some sort of penalty? And how often are audits even happening these days?

So, I mean, I've seen people do some cute things to, to work around these, these rules. The. I would tell you this. I mean, at the end of the day, I always think about the intent. Intent, you know, and so you're going to have to cross that threshold at some point. You know, I would worry that if, if you are in a relationship with the insurance companies where one doctor is coming in to see a specific group of patients, you know, what is the impact on patient referrals? What is the impact on new patients? You know, because there's two aspects of this, I think, that are really important, you know, sales and marketing. Sales and marketing never get talked about in dentistry, you know, like that. Right. So sales and marketing are also different.

Marketing is getting your practice out there, right. So people are aware of it. It's, it's a tra. It's getting eyeballs to focus on your practice. And so that can be done a lot of different ways. And a lot of people take. Participate in network with insurance to do that. Right. So they get people to the. But, but more and more people are in network and so it's becoming less and less of a distinguisher, right. Of a distinguishing factor between practices. So it's the, the effect on marketing is less and less. And it's more on sales. It's more on, hey, I'm marketing through postcards or online or pay per click or whatever. I'm doing billboards and so on. And now the call is coming in and I'm talking about converting them to a patient. I'm trying to get them to schedule. And that's where insurance plays a role. And so if you do a really good job on the conversion conversation and you, you can work them through. Are you in network? Are you out of network? What's the impact? I think you can manage it a little bit better when, when we go to how people are working through these different challenges with insurance. I mean, people commit insurance fraud every day, all the time, because they don't know any better. Because what happens is. And I'm not saying that the situation you gave was. But I think, you know, when you get cute, you, you put yourself at risk. Because what happens a lot of times is if you file under a different doctor. So sometimes we work with clients, we find out that they've got a bunch of associates when we start working with them, and they never got credentialed. And the doctor says, well, they're not going to be here but two years, so I'm not going to spend the money to get them credentialed. Well, you can't do that because you can't tell guardian that to go see this, you know, to go see this office and have a provider that's not, that doesn't necessarily meet Their standards, that doesn't work. That's, that's, you're not allowed to do that when you provide discounts. A lot of times we have patients that are providers that say, hey, I want to provide this patient a discount. Well, the insurance company is responsible for a portion of the payment. So if you give a discount to the patient, you also have to discount, give a discount to the insurance company because they're only responsible for 50%. So if you, if you file a claim for a $1300 crown and you only make the patient pay, you know, $200, then the, the relationship's not split. 50. 50. Right. The insurance company is supposed to pay 50% and you're only charging the patient $200. So then the insurance company should only paid $200. Right. So there's a lot of things you could do. So, you know, in that specific example, it sounds like everything's fine. I don't know how they file the claims. I really can't speak on that. But there's a lot of things when people try to get cute and work around the intent of what the insurance companies are trying to accomplish that could get you in trouble. If that. Does that make sense?

Yeah, that does make sense. A lot of times it's almost like the insurance companies don't consider or really even care about the cash flow predicament during that point of transition those sort of few months afterward. To them, they don't even give it a moment thought. But to the buyer, it's a significant thought. It's how do I stay viable during those three to six months? So usually what I've done is I'll.

Sort of support from an accounting standpoint, whatever situation that the buyer and the seller feel comfortable with, as long as it's not clearly egregious. Like in this case, technically the seller has his own corporation. Technically he is doing the treatment. Technically he's billing under his corporation. Delta would, would never even know unless they came in and did some really deep audit there. And then they're going to remit the payment back to the buyer until the buyer's credentialed. And the buyer needs to just deal with that cut. That eventually is going to have to happen if they want to ride that out a little bit longer while the seller continues to work there for period of time to get the extra Delta Premier layer. That's, that's going to be kind of up to them. I don't see audits too much, although I do have a client who part time does audit for For Delta, they do happen. I don't know what the consequences of somebody who's doing some insurance or billing fraud happens, but, you know, it's not.

Often from my experience, but it, it's things that you don't expect. Right. It's the little lady who calls up and says, hey, there's a discrepancy on my EOB. Because remember, all the EOBs get mailed to the patients as well. Right. And she says, well, I don't, you know, that's not the doctor that I saw. And they're like, oh, wait a second, you know, and then 10 calls come in later and all of a sudden they're like knocking at the door saying, wait a minute, I got to see your records. You know, so little things like that. But, you know, I think the example you gave, I appreciate.

Creative solutions that allow you to take advantage of, you know, legacy situations. So I, so I don't, I don't want to come across that I'm not open to, you know, being creative. But I, but I. People get a little bit overzealous sometimes when they're looking to, to beat the system.

Yeah. But I do like how you brought up marketing and sales, that if you see a big picture, the biggest thing you could do for your practice is create this amazing brand name for it out in your space, in your geographic space and give patients an unbelievable experience where it price matters a little bit less. Because dental insurance plan, they're just discounted plans is the way I've heard it one time. And that's really what it is. Like I look at my medical insurance, the only thing I care about my medical insurance is catastrophic coverage. Because thankfully my family's healthy. I never hit my premiums. So I've actually gone with one of these sort of Christian based programs where I literally pay, I think it's $400 a month for my family of five. And I cover everything out of pocket because I'm tired of paying $2,000 a month in a premium and I'm still never hitting my deductible. The only thing I care about is a massive car accident and I've got $1 million of medical costs. That's the main thing for me. But in dental, you don't really have that. This is really getting a discount on your dental services. And so if you can create the type of patient experience and brand recognition about your practice where people look at you and say, okay, I'm going to pay a little bit more with this doctor. But I know that that Dental work is going to be done clinically, just totally right. It's going to be excellent. My smile is going to look great, my teeth are going to be, you know, last a lot longer, whatever that is, so that they feel is great value out of it. The discount which comes with the insurance doesn't matter as much. Which is one of the things that I've advocated a lot for doctors is can you go out of, can you go out of network and become more fee for service? Now, I know that sort of your involvement in a practice becomes less relevant if somebody is fee for service, but maybe not. Are you still involved with out of network companies and do you think fee for service practices are just invariably becoming a thing of the past?

No, I. So it's a good question. You know, it's all about. So a couple things, you know, number one is.

You have fixed costs, right? You started talking about this at the beginning. So you have indirect costs, you have direct costs. And most dentists, I think, see most of their costs as fixed. And so you've got a monthly expense bill to hurt to, you know, to get over, right, Every month. And so I think you take insurance or you do things to drive volume to the practice until you can very safely clear that number very confidently, you know, and start earning the type of income that you're looking for. As you're doing that, you have to measure your capacity. What's the appropriate amount of time to be scheduled out? Is it two weeks? Is it six weeks? Right. What's how much of your work is hygiene and how much is that translating into, Doctor? You know, work, Right, dental work. So how much is how many new patients are you generating? What's your attrition rate? There's these different.

Key performance indicators, let's call them KPIs, right, that you have to evaluate in your practice to determine if you're at a point where you can leave insurance plans. And then there's a structured way to do it so that you don't cut off your nose one day despite your face, and you say, I'm done with insurance. They denied this crown, you know, to hell with them all. And I'm gonna just drop all my insurance plans, right? And then six months later you're like, man, it's awfully quiet in here. What's going on? You know, so there's a very structured way to do this. So, yeah, I think, you know, once you are at a point where you've built that brand recognition, once you're at a point where your schedule's full and people value what you're doing and you've built long term relationships, you've got a good healthy new patient flow coming in, then yeah, I think it absolutely makes sense, you know, to leave insurance and then it starts to get into, okay, which one? Right, and how long will it take and what do we do to communicate that to our patients and how do we get them to feel comfortable? You know, are there different options we can give them alternatively? So you just start working through this process whereby then you start leaving plans. So then, so we help doctors do that. So we help doctors who are fee for service who are saying, hey, maybe I'm not as busy as I'd like. I'd like to. Maybe I feel like with COVID and everything that happened, I should go and network to help my patients because they're financially struggling. So we help bring them into insurance and we help get them out of insurance too. So that's, you know, equally part of some of the things that, that we do on a regular basis.

I think that's really critical. If somebody's taking 20, 20, they're in contract with 20 PPOs. Should they be in contract with 20 PPOs? Probably not, I would think. Could they be in contract with three to five PPOs? Yeah, maybe. So I imagine what you might do is go through and understand all the fee schedules with those 20 PPOs and just sort of start at the bottom. And just as soon as the doctor is at a certain sort of capacity and their schedule is kind of booked out, you knock off the bottom. You just keep working your way up until you get down to just a few and maybe eventually you're completely out of network.

That sequence of events, that sort of thinking and that methodical way about dealing with your PPOs, I think is one of the most important ways for doctors to become financially successful, financially independent, which is what we ultimately are helping doctors do. I think they have to tackle that dragon at some point of not accepting every and all PPO and getting out of it. I think they need to be very, very methodical about that.

It's also interesting because, you know, we've done the opposite. So let's say you have a practice that you acquire and you can no longer be in premier. And so now you're just Delta PPO and 25% or 35% of your practice is PPO. And we know that that's about a 50% reimbursement rate. We might actually add you in plans that pay at a much better rate to try to Dilute out delta or dilute them down right, to 20% of your practice or something like that, where then all of a sudden it's much less important to your practice or gives you a pathway to potentially be out at some point. Right? So there's all kinds of different things that you can look at in terms of how to use these different insurance networks to accomplish, again, your goals that you have for the practice.

It's like you're trying to take your cards and you're trying to turn some in and take from the deck to get a better hand. And some of these insurance companies that you inherit when you buy a practice that the old practice was doing are maybe really crappy and there's better ones out there. And initially you may need to take those to keep the chairs full. And so you take these ones while you let these ones go. That's a really good point. It's not just about eliminating. It could be about recon, reconfiguring the ones that you have to get more cash flow. And then you could sort of work down the list over time to go out of network and become more of a, of a fee for service practice. Let's talk really quickly about the DSOs. And I'll say DSO, but I'll just say the larger group practices, whether that's five practices, whether that's 20, or whether that's 200. What level of negotiating power do you have as you combine with other practices, either through an informal kind of affiliation or through an actual common ownership or, you know, or through a centralized management entity called the dso? Is there negotiating power there? And second question on that is I find a lot of the big ones take a lot of hmo, which I don't, and my clients don't deal with. They don't accept a whole lot of hmo, although I think some of the real big ones, like pds, do take a lot of hmo. Tell me about those two question. Number one was, does scale give you negotiating power? And then number two, do HMOs have a place in any of this for doctors buying practices?

Yeah, it's really good questions.

The, the DSO question is interesting because it's evolving so rapidly and insurance companies, you know, you can buy practices faster than insurance companies can change their policies. You know, so we're seeing a lot of change there. Of course, scale does bring you value in terms of when you sit down at the negotiating table, but we're seeing more and more insurance companies trying to figure out how to navigate this.

Right?

Because every day you turn around and this DSO is affiliated with these practices. And now they went from four to 12 practices to 18 practices in, in five months. You know, and so it's really easy to buy practices and it's not as easy to, to operate them and bring them in clinically. And you know, so, so we're seeing the DSOs at some point. You know, they get to these maybe steps, if you want to call them that, and they're business growth and they have to stop and pause and focus on the operations. And that's usually a good time when they go back out to the payers, reevaluate their contracts, reevaluate their, their rates.

Because when you start bringing practices in as you're acquiring them, they all have different strategies. And so what happens is this guy over here is practicing in these six networks and this gal over here, she's in three networks. And this office is in every plan. And when you start bringing them together under one umbrella, you know, it really creates a lot of administrative headache. So, so there's a lot of challenges on the DSO side. But yes, certainly scale gives you, gives you some advantage relative to HMOs. We don't see it too often. I don't particularly care for HMOs in terms of their structure. I think it makes good people do some crazy things because essentially what happens is you get paid regardless if the patient comes or not. Right? So the patient in an HMO has, has to commit to you. And so when they commit to you, then there's a capitation check that goes to the doctor for every, every person that subscribes to that practice. And so you're getting paid regardless if they show up or not. When they show up, everything's very, very discounted. You talk about a PPO fee schedule being bad. HMO fee schedules are the worst. Right? So you're talking about cleaning is free, X rays are free, exams are free, it's just a $10 copay. So someone's in your chair for 45 minutes for $10. Right. But you're getting that capitation check every month. Right. So you're going to pick up maybe 50, 60, $80 over the course of year from that person. So there's a lot of people that then add on all kinds of different fees. There's, you know, they just, I don't, I don't like the, the incentive structure that it creates is not one that is conducive for a win win relationship. And so we try to stay away from it. Yes, a lot of the big groups do it because they have the scale to be able to, to do that. But it's only 10% of the marketplace. So I've used the number. 80% of people have dental benefits. 10% have a, have an HMO. So it's a very small and stagnant population in the marketplace, and it has its fit. I mean, if you, if you were a member and you had a great hmo, doctor, dentist, I mean, that would be a great, great option for you. But, you know, we, we tend to try to steer away from that.

Good answers on those. All right. I think my final question relates to.

In medical, billing is typically outsourced. In dental, it has not been outsourced, although I'm starting to see it outsourced among a few of my clients. And there are, of course, some outsourced billing companies.

Do, do you think that that's a good idea? And do the, these outsourced billers, are they able to sort of work the PPO system a little bit more, a little bit to the doctor's advantage in getting higher reimbursements? And do you think it's an idea to bill outsource billing?

Yeah, I think it's a great question. You know, I do. I think that my experience so far has been that they're good at billing. They're not. They don't do the aspect of contract management that we do, where they're going in and optimizing the way that you're participating and the rates that you're on and things like that. But they will take a claim and make sure that, you know, you get the money for it. Right. And, and so, and you got everything accounted for in your system. You know, books are updated and all that stuff. So I do. Because, you know, one thing that I'm, I'm thinking about here is we just went through a of, lot, lot of turnover.

So, you know, dental, we're, we're working with over a thousand clients across the country and we are every day being introduced to new office managers because through Covid, they laid their team off and they didn't bring all their team back. Right. Or a new insurance coordinator or the front desk lady is now working from her house in Florida. And, you know, she moved, they moved. Right. There's just all these changes that are happening in the, in the, in the market right now. And, and so I think about the challenges that a dental office has with a small staff.

Right.

You're talking in an office. How many people do you think are. What's the staff look like in a million dollar practice staff, they usually have.

A two front office staff. They'll have, oh, I don't know, a couple hygienists, depending on how much they work, maybe eight, eight hygiene days, maybe four ops or so. But a couple assistants, that's, that's what I'm seeing.

Yeah. Okay. So, you know, for, for two front office staff, you've got all the responsibilities of making the office work. Right. Non clinical. Right. So they're confirming appointments, scheduling appointments, answering. They're up. You know, hopefully they're on social media. Hopefully they're doing things to drive patients to the practice, they're calling on insurance to verify benefits, they're filing claims, they're chasing patient AR, they're chasing insurance, AR. They're doing all these things. And so, you know, I like the idea as the business of dentistry gets harder and more important, I like the idea of having people that do it well in charge of it, you know, and so I don't have to have somebody that, you know, a lot of questions are coming back about what's the pay rate right now? Because nobody wants to be in the dental office wearing all the ppe. So, you know, I've seen pay rates for hygienists go way up.

What about, you know, them calling in sick? Right. Or you have all these challenges with having, having employees. Right. And so I, I think it makes a lot of sense to, to use an outsourced billing company to do your, your dental billing. I, I, I just would also say that make sure that you're doing the right things because they're going to just do what they need to do.

Right.

They're not going to go in strategically, at least so far. It's like you said, it's very early on. I haven't seen them go in and strategically work to make sure the contracts are in the best spot and that you're in the networks that are appropriate for your goals and your capacity and the demand and all that kind of stuff. So while it's early, I do like the idea. So I'm anxious to kind of see where this goes.

Yeah, I think it's going to become much more prevalent over time. And you're right, the ones that I've seen, they don't deal with the strategy around negotiating the ppo, setting up which, the right ones and doing that whole analysis that you guys do, I see them being very effective at processing the claims very, very well because that's all they do. But that's the way that so much of business is going now. And with practice management softwares like eaglesoft and Dentrix going online, there's Dentrix, Ascend and Eagle Soft, I think it's called Fuse. There's a lot of, there's a lot of them. Curve was built all online. That IT being online allows remote billing to be done a lot easier now as well. A lot of companies now outsource their it. For example, I know a lot of companies, you know, are. We're sort of an outsourced CFO for dental practice. We're not just the CPAs. We're very involved in creating a financial arrangement or system within their practice for them to get ahead, as a chief financial officer would do in any business. And technology has allowed companies to outsource things and get the benefits that typically only larger companies have had in the past. Now they're able to get those even though they're a smaller company. And I think that's going to be absolutely critical for the small dental practice, the private dental practice, to succeed in the future. And is they have to figure out a way to incorporate those benefits that large companies get into their practice. And companies like yours, for example, the big companies out there will have in house or they'll definitely do outsource consulting to figure out how to strengthen their revenue model. Well, a company like yours is sort of an outsourced way of getting coaching on their revenue model, dealing with these PPO contracts. And, you know, there's a lot of that happening in the industry today. Hey, Nick, any final words for young associate or associates in and coming out of dental school to help them succeed as a practice owner?

Go get them. You know, it's.

I don't think it's ever been more exciting to be in dentistry. I mean, the, the, the rate of innovation and change is, is phenomenal. The opportunities are phenomenal. The, the knowledge that you can have and grow and diversify from just dental into business. And I mean, it's, you know, I, I think it's really exciting. I think it's really exciting. And, and so I would say, you know, if you're, if you think that being a business owner is in your future, listen, listen to the podcast like this, you know, with Associates on Fire and all the different topics that they cover and the different people that they bring in with expertise on different areas and grow your knowledge and work it, you know, it's very exciting and I wish you nothing but the best.

Nick, thanks so much for being on the Associates on Fire podcast. I'm sure sometime down the road. I'd love to have you back to continue the discussion.

Thank you so much. Appreciate it.