As predicted, 2017 continued a trend of more insurance companies trying to downgrade to the lowest paying option you are contracted with for payment. It used to be that a direct contract would override shared networks/third party admins and, for some companies, this is still true but not for others. A few shared network changes of note for 2017:
United Concordia added Lincoln and Ameritas to their shared network agreement. An opt-out is available for these but an office participating with UCCI will automatically be opted in without an opt-out letter being submitted. A direct contract with Ameritas does NOT override UCCI. Principal and First Dental Health were already added to the UCCI shared network agreement at the end of 2016.
Connection Dental and Cigna ended their shared network agreement. Cigna Advantage requires a direct contract. Other third-party administrators continue to have shared network agreements with the Cigna DPPO network.
United Healthcare and Guardian added a new shared network agreement in Dec 2017. A direct contract continues to override.
Maverest was bought out by Zelis. Maverest fee schedules already in place were allowed to remain but Maverest no longer exists as its own entity, it is being managed by Zelis.
Careington Platinum Specialists did not have access to MetLife (PDP+) in the past but a trial sampling of some offices has started to occur in December 2017. At this time it’s a limited number of offices being affected.
Colorado joins the majority of states passing laws prohibiting the insurance companies from forcing dentists to honor PPO fees for non-covered services. SB 190 was passed effective 8/9/17. Read about the law here.
Delta continues to be a concern for dentists as restrictions expand on the PPO vs Premier contracting options on a state by state basis. Do a careful evaluation of your practice make up to know what amount of your practice is tied to Delta, know what your state’s options are and how to take both a short and long-term view of how Delta fits into your practice.
Recredentialing packets are normally received from each insurance company about every 2 years. These don’t affect your insurance negotiations, they are information updates required to keep your current contracts in good standing. Be especially careful now with recredentialing! If you do not return recredentialing by the due date you will be bumped out of network and, if that happens, you may not get your previous fee schedule reinstated. When you get recredentialing requests make sure you not only return them, but that you also verify they were processed by having your staff call to confirm. Even if you sent the requested information, if the insurance company doesn’t show it as logged you’ll still be termed and some companies are using third parties (Humana using Medservant for example) where it can be difficult to get resolution if you get termed. Finally, with recredentialing be sure you read your paperwork to make sure you are not voluntarily giving up your ability to charge full fees for non-covered services or other changes that may be slid in if you do not read carefully.
There was a recent newsletter that set off widespread panic with an announcement that insurance companies/TPAs would stop allowing out of network benefits in 2018. Employers may choose to limit out of network coverage as they always have but there was no massive policy change in 2018 that wasn’t already in place before. A caution that, as more consultants attempt to move into this hot topic of insurance contracting, there is a good deal of misinformation being generated. Do your due diligence in confirming information directly with the carrier before assuming what you read or hear is accurate. Some information being spread is just plain false.
For those offices who are contracted with PPOs and plan to continue to remain so, we absolutely believe the solo dentist can still negotiate and strategize contracts as well as, and usually better than, corporate offices. The complexity of optimizing contracting makes it much harder to do for larger offices. So much so that we don’t think it is possible to do it on a larger scale the same way as a solo practitioner can do. We’ve been approached from every angle to do larger group and corporate negotiations and have always declined because what we do for solo dentists can’t be done on a larger scale with the same, customized results. While there are continued PPO challenges ahead, we still see solo practices as very competitive in the PPO negotiations area.