NMDA Journal Winter 2019-20

8 New Mexico Dental Journal, Winter 2020 Because the dentist is directly contracted with Principal, the dentist has agreed to contractual fees for those three codes at $683, $189 and $720 for a total of $1,592. Write-off is 32%. Connection Dental is an umbrella company and one of their clients is Principal. The den- tist’s contracted fee with Connection is $784, $232 and $819. Total of $1,835. Write-off is 21%. If the dentist was not contracted with Principal and was contracted with Connec- tion, they would expect to be reimbursed based on the Connection fee schedule. Cau- tion—it is likely that not all individuals with Principal PPO dental coverage are eligible for care in an office that is only seeing patients with Principal coverage through the Connec- tion umbrella. Take time to understand the client relationship between PPOs and um- brella groups and more importantly, the limi- tations of various plans and how they blend with umbrella group panels. Zelis is also an umbrella company and one of their clients is Principal. The contracted fee with Zelis is $715, $278 and $861. Total of $1,854. Write-off is 21%. If not contracted with Principal, and the only umbrella groups contracted with is Zelis, the dentist would expect reimbursement based on the Zelis fee schedule. Same caution regarding patient availability. DenteMax is an umbrella company and one of their clients is also Principal. The con- tracted fee with DenteMax is $588, $171 and $677. Total of $1,436. Write-off is 39%. If not contracted with Principal, the dentist would expect reimbursement based on the DenteMax fee schedule. Ameritas is an umbrella company with Prin- cipal, a client. The contracted fees through Ameritas are $537, $131 and $580. Total of $1,248. Write-off is 47%. If contracted with Principal only, the dentist would expect reimbursement based on the contracted Principal fee schedule. If, however, the dentist was not directly contracted with Principal but contracted with one or more umbrella company that Principal uses, what reimbursement is expected? As a business decision, Principal would likely use the reim- bursement schedule that is most advanta- geous to them. Under this scenario and many like it, the question that is often raised is, “Which fee schedule will be used to determine reim- bursement?” With the recent changes in reimbursement protocols the door is open for Principal to use the fee schedule that is most advantageous to their business interests. As a result, should Principal use either the Connection Dental or Zelis network, the reimbursement level would require a 21% write-off. If they reimburse based on DenteMax, the write-off would be 39%. Should they reimburse through Ameri- tas it would require a write-off of 47%. Principal is in the business to provide dental coverage primarily for their client’s employ- ees and like any other company, will gravitate to make sound business decisions. In recent years, it is uncertain as to which umbrella company’s fee schedule is used to determine reimbursement. Internal policies change and evolve but, in the end, when insurance com- panies have options given to them by provid- ers…they will use them. In conclusion, it behooves every participating dentist to be acutely aware of the potential processes available in determining reim- bursement and carefully evaluate participa- tion with umbrella companies. Participation may be advantageous to a dental practice or conversely, reduce a practice’s bottom line. Having the privilege of serving member- dentists through the Dental Cooperative for the past twenty-one years, a great deal has been learned about how independent dentists are reimbursed. Using the Messenger Model as outlined by the ADA, the Dental Cooperative works closely with many insur- ance partners to maximize Co-Op member’s contractual fee schedules. Standing in be- tween the provider and third-party carriers has offered great perspective. Doing so in the spirit of partnership, has given us a much bet- ter understanding of the radically changing world of how a dentist is reimbursed…and how to assure fees are being maximized. The Dental Cooperative is the largest, and oldest organization of independent dentists in New Mexico and throughout the United States. Please consider membership by join- ing other like-minded dentists seeking to strengthen our cause of preserving and em- powering the independent dentist. Feel free to contact New Mexico’s Area Director, Rio Padilla, for more information at 575-224-6722 and to see if membership can strengthen your dental practice. www.dentalcooperative.com  continued from page 7 Many patients fall into the trap of assuming dental insurance has similar qualities of health insurance. Comparing the differences in annual maximums between dental and health insurance, quickly identifies that the two approaches are very different. Andrew Eberhardt Dental Cooperative, COO Dr. Steven Peacock Dental Cooperative, Director of Special Projects