Dec 20, 2023 4 min read

Preferred Provider Organizations (PPOs)

Typically, dental insurance coverage in the US is either a PPO or HMO. Preferred Provider Organizations (PPOs) indicate that a network of dental professionals are employed by the patient’s plan at fixed, reduced prices. Although limiting in terms of certain services, PPOs are the most common type of dental plan and account for 74% of the total maximum benefit.

What Are PPO Plans and How Does It Work?

In a PPO plan, patients can select a variety of dentists from a large professional network who have agreed to accept a set fee for treatments. This means that the practices charge a discounted rate that is paid in full rather than the standard fee. A portion of this reduced charge is paid by patients when they visit the practice, with the remaining amount being covered by their insurance. Depending on the treatment, the percentage that the patient pays is typically low and represents simply a portion of the discounted fee as opposed to being charged the whole cost of the service. Because of this, PPO dental insurance plans frequently have the lowest out-of-pocket costs if the patient chooses in-network providers.

Under a PPO plan, major and extensive procedures, including fillings, extractions, root canals, bridges, crowns, dentures, inlays, and treatment for gum disorders, offset at a discounted co-insurance fee, while preventive care services like x-rays, sealants, fluoride treatments, and annual visits are covered at 100%. Therefore, the practice staff need to be aware of these in order to make the most of the PPO plan. These requirements not only have the maximum overall benefit but also increase the possibility of receiving the entire amount due for the services provided.

What Are Covered Under the PPO Plans?

  • Preventative Care Services like annual cleanings, X-rays, sealants, fluoride treatments etc receive full coverage
  • Basic Procedures like treatment for gum disease, fillings, root canals, extractions etc receive Discounted Co-Insurance Fee
  • Major Procedures like crowns, bridges, inlays, dentures etc receive a discounted Co-Insurance Fee
  • Cosmetic procedures like teeth whitening, shaping, veneers or any gum contouring will not be covered
  • The patient is required to pay the full cost of anything that is not absolutely necessary for maintaining their dental health

Benefits of PPOs

  • PPO participation acts as one of the main reasons for the greater visibility and new patient flow at your practice
  • Dentists must effectively manage PPO participation if they want to generate profits year after year.
  • Dealing with PPOs can help you attract patients you don't want to lose and also helps slow down any patient loss.
  • PPO insurance offers flexibility to both patients and dental professionals.
  • Regardless of in-network or out-of-network dentists, 82% of dental insurance policies in use today are PPOs.
  • As opposed to percentages determined based on the allowed fees of the plan, a PPO plan guarantees 100% coverage for diagnostic and preventative treatments.

Things to Be Careful of While Participating With PPO Plans

  • Several dental insurance providers check submitted fees on claims to determine the UCR, or ordinary, customary, and reasonable fees. The average fee for the demographic region will decrease if the PPO fees are billed out, which will result in lower pay for everyone.
  • Even if the claim is out of network, if you accept the assignment of benefits from secondary insurers, they will never coordinate up to a larger sum when compared to the amount you charge on the primary claim.
  • If you charge your usual rate on all insurance claims, the practice will receive a higher reimbursement because the payment will come from the patient's specific group under the insurance company and not the PPO network cost.

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