The Practice Didn’t Have a PPO Fee Problem — It Had a Billing Problem**
When this multi-provider general dental practice reached out for help, the owner believed their PPO contracts were the issue.
Production was strong.
The schedule was full.
New patients were steady.
But collections lagged far behind expectations.
Initial assumption:
“Our PPOs just don’t pay well.”
Reality:
The practice was losing revenue every day due to avoidable billing and coding breakdowns.
This case study shows how fixing billing best practices — without renegotiating PPO contracts — allowed the practice to recover over $120,000 annually in lost revenue while dramatically reducing claim denials and staff stress.
1. Practice Overview
Practice Profile
- Type: General Dentistry
- Providers: 2 doctors, 1 hygienist
- Annual Production: $1.25M
- PPO Participation: Heavy (70%+ PPO patients)
- Primary Concern: Low collections relative to production
- Initial Write-Off Rate: 34%
- Claim Denial Rate: ~18%
Despite solid production numbers, the practice struggled with:
- Frequent PPO denials
- High rework time for insurance staff
- Delayed payments
- Patient frustration over balances
The owner suspected fee schedules were the culprit — but the data told a different story.
2. Initial Billing & Claims Assessment Findings
A full PPO billing and claims review uncovered systemic issues, not isolated mistakes.
Key Problems Identified
A. Coding Inconsistencies
- Crowns regularly downgraded to large fillings
- SRP claims denied due to missing or incomplete perio charting
- Core buildups denied as “inclusive”
- Replacement codes submitted without narratives
B. Weak or Missing Documentation
- Generic narratives (“decay present,” “tooth fractured”)
- Attachments uploaded inconsistently
- Pre-op X-rays missing or incorrect
- No standardized documentation protocol
C. Eligibility & Frequency Errors
- Eligibility verified generally, not per procedure
- Replacement timelines assumed
- Frequency limits overlooked
D. Credentialing Oversights
- One associate billed under owner’s NPI
- Taxonomy mismatch for certain procedures
- Credentialing not routinely audited
E. No Pre-Submission Review
- Claims sent immediately after posting
- No checklist
- No second review
3. The Cost of These Errors
These issues resulted in:
- Denials that required resubmission
- Silent downgrades that went unnoticed
- Delayed cash flow
- Write-offs that were “accepted” instead of appealed
When measured annually, the impact was staggering:
| Issue | Estimated Annual Loss |
|---|---|
| Crown downgrades | $48,000 |
| SRP denials | $22,000 |
| Buildup denials | $18,000 |
| Missed replacement narratives | $14,000 |
| Eligibility/frequency errors | $11,000 |
| Total | $113,000+ |
And that didn’t include staff time, stress, or patient dissatisfaction.
4. The Billing Optimization Strategy
Rather than renegotiating PPO contracts immediately, the focus was on fixing billing fundamentals first.
Step 1: Standardize PPO Coding Rules
The team implemented:
- PPO-specific coding guidelines
- Clear rules for high-risk procedures
- Standard CDT usage protocols
This ensured consistency regardless of who submitted the claim.
Step 2: Create Documentation & Narrative Templates
Custom templates were created for:
- Crowns
- SRP
- Core buildups
- Replacement procedures
Each template included:
- Required clinical details
- PPO-friendly language
- Checklist of attachments
Narratives became strategic, not generic.
Step 3: Implement a Pre-Submission Review Checklist
Before any PPO claim was submitted, it had to pass a checklist verifying:
- Correct code selection
- Eligibility and frequency
- Required narratives
- Proper attachments
- Provider credentialing
This single step prevented the majority of future denials.
Step 4: Clean Up Credentialing
The practice:
- Corrected NPI assignments
- Updated taxonomies
- Verified participation status
- Implemented quarterly credentialing audits
Credentialing denials disappeared almost immediately.
Step 5: Train the Billing Team as Revenue Protectors
Instead of treating billing as clerical, the team was trained to understand:
- How PPOs adjudicate claims
- The financial impact of errors
- How billing supports practice growth
Confidence increased. Stress decreased.
5. The Results: Revenue Recovered Without Renegotiation
Within six months, the results were clear.
A. Denial Rate Reduced
- Before: ~18%
- After: ~6%
B. Write-Off Rate Decreased
- Before: 34%
- After: 27%
C. Faster Payments
- Average payment cycle shortened by 9–12 days
D. Annual Revenue Recovered
- Recovered PPO revenue: $120,000+ annually
- Without increasing production
- Without adding staff
- Without renegotiating contracts
6. Why This Worked
This wasn’t magic — it was discipline.
The practice didn’t:
- Add patients
- Add hours
- Add services
They simply:
- Submitted better claims
- Spoke the PPO’s language
- Prevented errors instead of fixing them later
Billing optimization allowed the practice to finally realize the value of its existing PPO contracts.
7. What This Case Study Proves
1. PPO Revenue Is Often Lost Before Negotiation Is Needed
Many practices chase renegotiation before fixing billing fundamentals.
This case proves:
Billing optimization should come first.
2. Clean Claims Increase Effective PPO Fees
Better billing doesn’t change fee schedules — it changes what you actually collect.
3. Denial Prevention Is a Growth Strategy
Fewer denials:
- Improve cash flow
- Reduce staff burnout
- Improve patient trust
- Increase profitability
4. Billing & PPO Strategy Must Work Together
Negotiation improves potential revenue.
Billing determines realized revenue.
8. How PPO Negotiation Solutions Helps Practices Replicate These Results
We help practices:
- Identify high-risk billing patterns
- Standardize PPO coding and documentation
- Reduce denials
- Recover lost revenue
- Prepare for PPO renegotiation from a stronger position
Billing optimization is often the fastest revenue win available.
Conclusion:
This Practice Didn’t Need Better PPOs — It Needed Better Billing**
By fixing daily billing habits, this practice:
- Recovered over $120,000 annually
- Reduced denials
- Improved staff morale
- Stabilized cash flow
- Strengthened long-term profitability
For practices heavily involved in PPOs, billing excellence is not optional — it’s essential.
Want to See How Much Revenue Your Billing Is Leaving Behind?
PPO Negotiation Solutions offers Billing & PPO Revenue Assessments that identify:
- Coding errors
- Documentation gaps
- Denial patterns
- Recoverable revenue
👉 Schedule Your PPO Billing Assessment
Find out what your practice could recover — without renegotiation.