PAGD Keystone Explorer Summer 2021

18 www.pagd.org Q dentistry issues Sweat the details. Any carrier will happily send you paperwork to complete, but they will be less helpful to review the terms and small print of your contract. Pay attention to the carrier’s relationships with their partner networks or Payor Lists, also known as Network Partners, Client Lists, Third Party Administrators (TPA), and Lease or Rental Lists. Some things to evaluate when considering accepting or dropping a plan may be: » Your primary relationship with the carrier, whether you are directly contracted or are “in-network” through a contracted Payor List. Go to dentalcoop.com/ reimbursements for a quick tutorial on the different kind of carrier relationships. » The pros and cons of contracting with a carrier that includes a large Payor List versus contracting directly with multiple individual carriers. » Understanding and knowing the carriers that will not pick you up as a provider on a Payor List after you have terminated your direct contract with them. » The time restrictions (30, 90, or 120 days) for being removed from a contracted carrier once you have requested termination. » The carrier’s re-credentialling schedule regardless of your recent contract effective date. Focus on the top. Create a spreadsheet with your top CDT procedural codes, full office fees, and your carriers fees that go with these codes. When talking about your top codes, remember to focus on your top dollar amount total production codes, not your most used codes, which is a subtle but important difference. You may have a code that is used a lot, but in your overall total dollar amount production, may not make the top list. For a typical GP, your top 25 codes represent about 80% of total production, and your top 50 codes about 95%. Your practice management software will easily produce this list for you. So don’t worry too much about the other codes and just focus on your top 25 or 50, especially when requesting a fee review from a carrier. Watch out for related codes that give the plan the option to downgrade to a lower code, for example: composite vs amalgam. In this case, make sure these two codes’ fees are not too far off from each other in case of a downgrade. Remember that less used codes may be increased while your most common codes may not. Just focus on your top codes, and after those, the related codes in case of downgrades. Scenarios: Let’s take a look at how a PPO plan would typically reimburse for CDT code D0120 Periodic Eval in a few common scenarios for a patient that comes in with a plan from Carrier A. You may be contracted to see this patient under several different signed contracts.