698: Shelley DeGroff - 2024 Trends in PPOs

Have you ever wondered about PPOs or struggled to understand them? Kirk welcomes Shelley DeGroff to shed some light on this complex relationship between dental practices and insurance. Shelley is the founder and CEO of PPO Advisors, a firm that helps dental practices turn their PPOs into profit. She talks about the trends of 2024, emphasizing the importance of understanding the percentage of write-offs and the need to evaluate fee schedules. The conversation concludes by encouraging dentists to play the insurance game with confidence and seek expert help when navigating the complexities of PPOs.

Learn More About Shelley and PPO Advisors 

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Main Takeaways: 

• Evaluate fee schedules and understand write-off percentages to ensure proper reimbursement.
• Regularly audit EOBs to identify discrepancies in fee schedules and reimbursement.
• Proper credentialing and negotiating contracts are crucial for setting favorable rates.
• Be aware of network shares and changes and regularly assess your PPO mix.

Quotes: 

“PPO Advisors is a negotiating contracting company that focuses on getting providers the best reimbursements they can get, but also educating providers on how to play the insurance game, helping those office managers understand the ins and outs of those contracts, the webs, the tricks, everything that comes with insurance. We want to be that resource to help them find success. So all PPO advisors does is advocate, educate and help find providers the best we can.” (02:01 - 02:11)

“2024 is going to look similar to 2023. I do think we are going to continue to see a higher trend of providers wanting to term out of insurance contracts. And I'm okay with that. I'm okay with them wanting to look into that. I'm never going to be an advocate of you have to be a PPO practice because let's be real, that is very difficult to be just strictly PPO. There has to be a healthy balance of your fee for service to PPO ratio. But we see the trend rising. What used to be a much lower number of fee for service practices, we are now seeing that number increase to where we're about 16% now fee for service. That number just three years ago was 6% from the ADA. We're seeing that rise and I want to see it rise even more because I do feel like as these providers realize that they can stay busy, they can have success being out of network with some of these insurances that just aren't serving their practice well, more and more providers will get confident with that.“ (02:57 - 03:57)

“In 2024, you know, we want to continue to educate providers that not knowing what your write-off level is, is more dangerous than attempting to do something about it.” (6:52 - 7:02)

“Don't get tricked by insurance. Make sure you're looking at the overall picture, what you produce, what codes you're utilizing. Most frequently, again, 10 codes bring in 90% of your production. So take a look at those 10 codes and really evaluate, does this fee schedule fulfill the goal we're after before you accept that fee?” (11:03 -11:10)

“Make sure you're doing some sort of increase every year to your fees to help the whole dentistry community with insurance keeping fees at a higher rate.” (15:12 - 15:23)

“The best way to audit your insurance participation is through the EOBs. You have to envision a web, right? So an office, when they tell you that we only signed up with one or we only signed up with two, all networks are interconnected. So the days of I signed up with an insurance company means I only got that insurance company, that's gone. All networks have a backdoor agreement to another network. So when you sign up, not even with just a TPA or an umbrella company, it can be a shared network.” (16:38 - 16:52)

“If you're not credentialing correctly, you are allowing the insurance companies to set your rate, right? You're allowing them to come in and do whatever they want to do to your practice because you're not regulating them.” (20:50 - 21:02)

“Big trends that we're anticipating, we are seeing several of the TPAs have increases this year, which is great. Last year in 2023, some of those bigger TPAs were on a freeze, meaning there were no increases available. So what does that mean for a practice? When TPAs open up negotiations, it does allow for different stacking of contracts, different options available that you can play within your practice.” (23:02 - 23:29)

“You're going to hear me say the word play a lot. This is a game. Insurance, negotiations, contracting has become a game and you have to be well versed in it in order to be able to play it successfully against your component. So with that, I hate to say that it's a game, but it really is and it's one that we have to take pretty serious.” (23:30 - 23:53)

“I don't think you should ever be comfortable enough to say, this is the set stone, this is in writing, and we're going to keep it this way for the next five years. That would not be looking at your practice successfully. In my opinion, this is a yearly evaluation. It's changing constantly, and you've got to be willing to change with it to see success.” (30:03 - 30:22)

“My take home is 2024 is a fresh year right in front of us. Learn to play the game and play it with confidence, whether it be on your own or with an expert, but know that there's always different options available. It's just a matter of understanding them and putting them into play within your practice. So there's always a change that's available. There's always an opportunity that can be had, but not making a change and not looking at what you can do is more dangerous than actually making the changes.” (30:37 - 31:09)

Snippets:

01:14 Introduction to Shelly DeGroff and PPO Advisors

06:20 Write-off Percentages

08:13 PPOs and Fiscal Years

09:41 Fee Increases and Negotiations

10:41 Evaluating Fee Increases

11:39 Master Fee Schedule

13:01 Credentialing and Setting Rates

16:23 Understanding Umbrellas and TPAs

20:43 The Importance of Credentialing

22:01 Negotiating Contracts

23:01 2024 Trends Continued

25:21 Network Shares and Changes

28:09 Switching PPO Mix

30:32 Making Changes and Seeking Help

32:58 Conclusion and Contact Information

Shelley DeGroff Bio:

Shelley DeGroff, founder and CEO of PPO Advisors, knows dentistry. After graduating from the University of Nebraska, she began working as a dental receptionist in a nearby dental office. After completing her certification as a dental assistant, Shelley transitioned to become a successful office manager. It was in that role that Shelley began noticing the need for PPO negotiations for her employing doctor. This experience began the business model for PPO Advisors, which has now become a nationwide industry leader.