Friction with Payors and Regulation Change

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The ADA recently asked a panel of 3,000 dentists about their goals for 2023 – almost three out of four dentists said they plan to raise their fees. Others were focused on hiring more staff and dropping out of some insurance networks.

For most dentists, setting fees is one of the most challenging aspects of owning a practice.  This is especially true for practices that rely on reduced-fee dental insurance plans and where fee-for-service (FFS) patients feel the brunt of a fee increase. This also creates challenges for the front office team members who are on the front lines of answering patient questions.

Practices contemplating going out of network, must proceed cautiously as revenue from those covered patients contributes to covering practice overhead even though it may not add much incremental profit unless the practice is of large scale designed for throughput, and with very efficient systems and processes.

Before going out of network, practices should do a full financial analysis and weigh the lost revenue from in-network patients who leave the practice against the incremental revenue earned from the new higher fee schedule. Does the estimated increase in revenue per patient make up for the estimated decrease in the volume of patients? Would you rather fill your chair with a patient who generates 2-3x production and collections than three patients with less impact?

One way to ensure that your patient does indeed generate 2-3x production & collections is with a membership plan, where patients sign an annual agreement and practices are assured to get 100% of their collections. Member patients typically visit more often and accept more treatment than uninsured patients. Practices set their own fee schedules, to share the savings with their patients, typically around 75-85% of UCR. The idea is that patients get savings and practices earn more per patient than they would have with an in-network patient.

Membership plans involve offering uninsured patients a dental care regimen for a set fee.  The practice determines which services to include in the regimen, usually biannual doctor exams, cleanings, annual X-rays, and an emergency visit. And many practices also offer a discount – say 10% – off restorative treatment.

These plans have been around for several years but warrant close consideration if you do not have one or reassessment if you do offer a plan. Now, there are vendors that help you customize plans of your choice & set pricing that is appealing to your patient demographics. These vendors sell software that will automate all the payment processing, the plan renewals and the notifications to your patients.

Dental City’s strategic partner, Plan Forward, is standing by to evaluate your current situation to see if a new plan makes sense or to reassess your current plan. With Plan Forward Advanced, integrated to >20 PMSs, practices will be able to:

  • View in-depth analytics showing the impact of membership on practice Collections and Production, and track KPIs like members’ hygiene recall, treatment acceptance & show rate.
  • See reimbursements by insurance plan for services, so you can rank order your insurances.
  • Identify patients who are candidates for your membership plan, and allow the technology to do the marketing – Plan Forward will help your practice convert uninsured & dormant patients to members at your own defined fee schedule.

Of course, effective marketing and communication is vital to success with membership plans.  Plan Forward provides an enrollment link for your website, so patients can sign up online, and all the marketing brochures to display in your clinic. They also provide training and scripts so your front office is well equipped to convert uninsured patients to members.

Before you decide to move forward with dental membership plans, consult with your state insurance regulations. These plans are not dental insurance but require careful planning to be sure that they are not construed as such.  Your state may have regulations that apply to these plans. Our recommendation: These plans are fairly straightforward to implement. But before you embark on your own, we’d recommend at least talking with a professional provider of membership plans.

On a related note, did you read about Question 2 in Massachusetts, which recently passed with a large majority?

Now, 83% of every dollar collected by payors must be allocated to patient care. Already, this change in the dental loss ratio is spreading to other states. Payors will have to consider exiting MA, and for those that remain, it seems inevitable that insurance premiums must rise, making dental insurance even less compelling for patients and consumers. There are currently 97m American adults without dental insurance. Let’s watch this number increase over the next 5-10 years. The best way to offer these uninsured consumers access to oral care is with proactive outreach and a membership plan.

About Plan Forward

Plan Forward offers a solution for designing, automating, and managing membership plans, for dental practices. Plan Forward offers a PMS-integrated technology platform, with deep analytics as well as the marketing and support you need to grow your members. Learn more about Plan Forward at

About Dental City

Dental City has been a trusted supply partner to dental offices across the country for 30 years. Offering an extensive selection of high-quality dental products from nearly 500 brands, and tens of thousands of products in stock and ready to ship with our same-day guarantee! When you order from Dental City you get exceptional customer service, deep product knowledge, the ability to track down hard-to-find products, competitive prices, and quick, accurate shipping. Learn more about Dental City at

For more information contact Dental City
at 1-800-353-9595 and ask for
Rylee, Dave, Jane or Jordan.