Insurance Fee Schedules Can be Confusing for Any Orthodontic Practice

Posted on January 11, 2019

In general, everyday Americans are just as confused about insurance as medical providers are. Yet, medical providers have a lot more to figure out, and that’s where it gets tricky. Sandy Luparello, Senior Director of Patient Financial Services at OrthoSynetics, works with 20 to 30 insurance carriers that offer dental or orthodontic insurance, and they all have different fee schedules, lifetime caps, and ways of billing.

“Typically, insurance companies want to keep you on their fees for two years,” she says. “Once that period is up, you can negotiate an increase in your fee schedule. Often, the first quarter of the year is the best time to negotiate. The insurers are usually more open to changes then.”

As we enter 2019, orthodontists should review their plans to see if it’s time to renegotiate fees. It’s not necessarily a level playing field since insurance companies have large staffs who do this stuff all day, every day. Practice owners need to have a dedicated staff to stay vigilant with insurance changes and opportunities in order to negotiate, or they can outsource the task to a third party. And as a provider, you still have leverage.

Remember: insurance carriers want a good number of quality medical providers on their rosters to make their plans attractive to employers.

When analyzing plans, whether an existing contract or a potential one, the first thing to look at is the fee schedule. Sometimes, when payments aren’t enough on an existing contract, the wise decision is to cancel it. Beyond the strict numbers, practice owners should also give weight to what services are all-inclusive and what services are billed separately.

“Say an insurance company has banding, brackets, and retention under one inclusive fee, but they allow pictures, x-rays and other records to be billed separately for another $250. That will generate more money for the practice,” Luparello says. “If the inclusive amount is already high, that’s great. On the other hand, if you have to bill separately, you may get more money in the end. The trade off, however, is a bit more administration and more room for missteps.”

Practices should also take the time to review their payer mix, which typically has three buckets: private pay, private insurance, and Medicaid. A diverse payer mix will help a practice stay competitive, while too much of one kind of payer can open the business up to vulnerabilities. For example, if a practice is heavily weighted to Medicaid patients, a state change in orthodontic policy can totally upend the business. Likewise, a sudden recession like the one we saw in 2008 can cause the private-pay patient base to dry up.

When deciding on participation in a plan, one thing a practice should keep in mind is that simply being included in an insurance provider’s list of approved vendors is a form of marketing. While discounting fees for insurance companies may be unappealing, being listed in a healthcare directory can drive patients and subsequent referrals to your practice. That’s a good thing any way you look at it.

“Consumers are becoming more and more savvy,” Luparello says. “They’re looking for price transparency and the best bang for their buck. Patients will often look at their in-network list first. They’re really using their benefits.”

Patients are twice as likely to use dental insurance to see a doctor compared to previous years, so she recommends getting on as many plans as possible. When signing up with a new insurance carrier, remember that the process takes time, lots of paperwork and follow-up. Whether you have a third-party provider handle the effort for you or you do it in-house, it may take up to 60 days.

Still, it pays to be judicious. If a practice accepts everything, the books could end up in the red. Also, when dealing with insured patients, practices should be totally cost transparent. For example, insurance often covers standard brackets, but not upgrades like Invisalign. If a patient chooses an upgraded treatment, the practice should get a signed waiver in which the patient acknowledges the upgrade. This is the best way to avoid liability issues and headaches if the patient complains down the road. Think of it as an insurance policy against an unhappy patient.

So, as you think about what 2019 will bring for your practice, think about using every bit of leverage you can when it comes to insurance carriers. You’ll be glad you did and so will your bottom line.

To learn more about how OrthoSynetics can help your practice with insurance services, please visit