Start Up Red Flags/Green Flags

By Lisa Weber

There are a few things that we’ve found as we’ve had the privilege to work with a lot of startups and I wanted to start a thread just to address those initial challenges.  We hope to prompt doctors who are about to begin on this journey to step back and think about their individual situations and do a bit of homework and self-evaluation before they move forward.


Undervaluing your treatment before you even open- Dentists who come to us with  current employment in either a corporate office or a high volume Medicaid office typically either want very little participation based on the fees they’ve seen or they think there is no other way to success than taking every carrier known to man.  Neither is true.  There is a reason that I typically do not want dentists to see what a carrier might propose for an initial fee schedule before they set their cash fees.  Too often, that $580 crown you’ve seen at your associateship makes you undervalue the treatment you’re going to provide at your new office and you set your cash fees too low from the very start.  Pedodontists are hands-down the group who typically undervalue their treatment the most, likely because they are more likely to be associating in an office with high Medicaid enrollment. STOP THAT.  I ask Startups to step back and set their cash fees like they are a completely FFS practice and that is a fee they are comfortable with for a particular procedure if they are going to be seeing a patient who has no insurance at all. If I can get 100% of their full fee from a carrier it’s not because I did an awesome job but because they’re not charging enough, and I’ll tell them that every time.

Starting too late- It’s very easy to be absorbed in the process of finding a site, getting a builder, figuring out what kind of chairs and PMS you want to use, and then realizing 60 days before opening that you have not even thought about insurance.  Reality check- Delta is taking on average 4 months in Texas, California, and Georgia if you are already IN network to be added at your new location.  Delta is likely to be your #1 carrier revenue source, in net or out.  If you don’t par, you have to collect in full from your patient at time of service.  Talk about a roadblock in your way when you’ve spent thousands to market to these same people to call you before you open and the answer when they call is “Well, we’re going to be in network but we aren’t, but if you pay us in full, we’ll file the claim and the check will go to you”.  This conversation happens every day.  If you’re intending to be out of net, that’s a crucial conversation that your team needs to be able to master (and if they can’t they shouldn’t work for you) but if you’re intending to be in network, you’re beginning your conversation with these patients in a position you don’t need to be.  Most carriers that are negotiable take a good 30 days just for negotiations, after you’ve set your top codes and fees and another 90 days in credentialing.  Plan accordingly.  If you rush, your fee schedules that will form the foundation of your insurance collections will reflect that.

Signing with everything because you’re afraid if you don’t, the patients will not find you.  Look up your ultimate zipcode like a patient would and see how many other providers are in net in your 5 and 10 mile radius.  If there are more than 20, they are not likely to find you that way anyway. They will see your signage, see your office, receive your marketing, or hear about you from someone who heard about you and then log in to see if you’re in their network.  What is that conversation going to be when they call?  You must pair your participation with other marketing because passively waiting for the listings to send people to you doesn’t work in a saturated environment and most environments are now relatively saturated.

Participate if it benefits you, not because it’s a rite of passage.  It’s only a benefit to you if what you receive outweighs what you lose and you need to think in the long-term, not just an immediate need to fill a chair.

Don’t burn your bridges- I know you may want to bail on that associateship as soon as you can, but the steady and predictable income from an associateship position will give you breathing room so that you are more likely to make decisions that will benefit you for the short term and for the long term.  It’s a far better feeling to find that you’re busy enough that you can drop days at that associateship faster than expected than the feeling that is associated with feeling you’ve got to go work somewhere for any paycheck at all, just to make payroll as you begin to develop your own practice. About 95% of our startups wish to keep their future plans confidential as they look at opening a solo practice and carriers are used to that request.  Give your employer notice if you can because it’s not just the right thing to do, it also preserves your ability to have an additional income as you focus on your new practice and it can be a positive for both sides.

Hiring a FD
– Don’t wait until 1 week before opening to hire a FD and then be surprised that the person you hire (with no dental experience) is having a difficult time entering insurance information, estimating copayments, using your new whiz-bang PMS.  Your understanding the software and having played with it in the trial version does not mean that your FD can do the same in an environment where they have calls coming in, a schedule to fill, and a dentist standing over their shoulder looking at what they’re doing.  If you hire someone with no dental insurance experience, that’s what you get.  It’s not brain surgery but it is not intuitive. They may have had experience with your PMS…they may have been trained by someone who was trained by someone who figured it out on the day the previous someone quit and none of those someone’s actually was trained well.  That person may bring some awesomely bad habits to your practice because she doesn’t know any different.  If you do complex dentistry, understand that it also comes with complex claims.  If you hire someone who has LOADS of experience, make sure to do the PMS training with them in advance of your opening and you may find that the resume was inflated.  A lot.  I’m actually a fan of hiring people and teaching them the way you want them to do things. If you don’t know how to file claims or use your PMS, you can’t teach them so you need to make sure you budget enough to hire someone from the PMS company you’ve signed on with who can.  Your data is perfect before you open.  Everything that can happen to totally screw it up begins to happen on Day 1. Know how to navigate your PMS well and where to find everything.  Do not allow yourself to be hostage to any single employee or you’ll make allowances for the person you want to let go, simply because you don’t know where to find things. Remember. They came to see you, not the FD, no matter how awesome she is…promise.

Teach your FD , hygiene and assistant your own language- Review the procedures out loud that you’ll do in the same way you will explain it to your patients. Ideally they echo and reinforce you and if they have questions about what you’ve just said, assume your patients will as well so you need to rephrase so that everyone understands.  Your FD will not see red flags in treatment plans or estimates if she has no clue what the procedures are.  Teach from the beginning in Hop on Pop language and just like you would talk to your patient.  Do this even if they have experience because you’d be amazed at how some have always misunderstood a procedure and parroted that misunderstanding to a patient.  Bad communication is a really good source of lousy copayment estimates.

Not learning from mistakes– Balances that a carrier didn’t pay or a patient didn’t pay are not reasons to berate your FD in the first week of their employment.  Nope.  If there are balances, you’ve either not hired well or not trained well.  It’s your fault, sorry.  Balances to me are going to happen and are an opportunity to step back, figure out how it happened and put into place systems to keep it from happening again.  There are reasons PMS programs have note sections in the employer and carrier fields.  Use them.  Each day doesn’t have to be Groundhog Day.  You can take a balance, and turn it into a template to understand how that carrier will behave when it gets claims for other patients and prevent surprises in the future.  A balance that is unexpected that doesn’t generate action to prevent it from happening in the future is a wasted opportunity and also more likely to be the reason a patient leaves you than they’d leave you if you hurt them. They are expecting you to hurt them and are pleasantly surprised when you don’t. They are not expecting a balance of $75 in the mail and will leave you because of it.  A dentist once told me that he was making his FD go over all claims with him first to make sure they were correct.  I asked him if he knew what it should look like and he admitted he didn’t.  This startup specialist is on his 3rd FD in the first year of his practice because they’ve left. None of them received training by their PMS.  From personal experience, hiring, firing, and replacing is a very expensive process and it’s far better to get the right person and give them the right tools from the start. Check out Sandy Pardue’s threads and do nothing but read.  Please.


Pay attention to the Red Flags and share your experiences because this generation of startups is building on each of your successes and are being cautioned in advance on other challenges by those who have gone down the same path.  Thanks to DentalTown (visit  you honestly don’t have to go it alone because there are loads of resources here if you just search. Plan ahead, give yourself time, and give yourself  credit for being someone who a patient would want to see PPO or not, and the patience to deliberately focus on making your dream come true.  It will.