As a dentist, the insurance plans you choose to be in-network with can significantly affect your profitability, patient volume, and stress levels. While being in-network can attract more patients, not all plans are created equal.
Here’s how to evaluate which dental insurance plans are worth participating in and which might cause more administrative headaches than they’re worth.
1. Reimbursement Rates: Are You Getting Paid Fairly?
Low reimbursement rates are the #1 reason dentists drop insurance plans. Before joining any network, ask for a complete fee schedule and compare it to your UCR fees. Pay particular attention to commonly performed procedures like:
- D1110 – Adult cleaning
- D2740 – Crown (ceramic or porcelain)
- D2391 – Posterior composite filling
- D0120 – Periodic oral exam
- D0150 – New patient exam
Plans with bottom-tier reimbursements can erode profitability, especially when combined with increased overhead and supply costs.
Pro tip: Some newer or regional PPOs offer better rates than national plans to attract providers.
2. Patient Coverage: Can Patients Actually Use Their Benefits?
Don’t just look at reimbursement – consider how much coverage the plan provides to patients. Plans with low annual maximums, long waiting periods, or high coinsurance for major services often delay or prevent patients from getting needed treatment.
This directly affects your production: If the plan only covers $1,000 a year and the patient needs $2,500 of work, they may decline treatment entirely.
Look for plans that offer individuals and families the following:
- Annual maximums of $2,000 or more
- Minimal or no waiting periods
- Good coverage for crowns, bridges, periodontal care, and orthodontics
3. Claims Processing and Pre-Auths: How Painful Is It?
A plan might offer decent fees but cost your team hours each week chasing claims, calling for pre-auths, or fighting denials.
Key questions to ask:
- What’s the average payment turnaround time?
- Do they require pre-authorizations for basic services like fillings or crowns?
- How often do they downgrade composite fillings to amalgam?
- Do they offer online portals or real-time eligibility checks?
The more complex the process, the more strain it puts on your front desk.
4. In-Network Employer Base: Who Are the Plan’s Members?
Plans that cover large employer groups in your area tend to send more new patients your way. Ask a dental insurance representative if the plan is offered by local schools, hospitals, city workers, or large corporations. This can give you a better sense of long-term patient volume and retention.
Some insurance plans tend to attract more individual buyers, such as those looking for discount plans, which can lead to less predictable and more price-sensitive patients.
5. Patient Expectations and Reviews
Certain plans have a reputation among dentists for being frustrating to work with and among patients for limited coverage or out-of-pocket surprises. Both can create tension in the chair.
- Look up online reviews of the plan
- Ask local colleagues for feedback
- Review DenScore’s “Best Dental Insurance” directories to see which plans are most recommended in your area
Summary: What to Evaluate Before Signing a PPO Contract
| Factor | Why it Matters |
|---|---|
| Fee Schedule | Affects your profitability on every procedure |
| Patient Coverage | Determines case acceptance and treatment completion |
| Claims Processing | Impacts your team’s efficiency and overhead |
| Employer Access | Drives long-term patient flow |
| Waiting Periods & Downgrads | Affects patient satisfaction and treatment acceptance |
Not Sure Where to Start?
At DenScore, we help dentists understand which insurance plans are worth joining based on:
- Reimbursement data
- Patient search trends
- Local employer coverage
- Real-world plan reputation
Being selective about which dental plans you accept can protect your time, increase your collections, and improve the patient experience.
Still need help finding the right plan?
Contact DenScore today and our professional relations team will provide key insights (completely free) to make sure you don’t choose the wrong plan for your practice.
