| Client Profile | Multi-provider general practice, Midwest metro suburb |
| Engagement | PPO Participation & Optimization Assessment |
| Execution Window | 6–8 months | Complexity: Level 4 |
| Identified Opportunity | $63,000 in projected annual gains |
The Situation
PPO Negotiation Solutions had worked with this practice once before — during an ownership transition, handling the credentialing that established network participation and positioned the practice for growth.
Then three years passed.
No network optimization. No fee negotiations. No reimbursement review. Meanwhile the market moved: carriers restructured network relationships, reimbursement models shifted, and in late 2024 insurers gained new visibility into the fees practices actually submit on claims.
The owner reconnected with a straightforward question: are we leaving money on the table?
Straightforward questions rarely have straightforward answers.
The Strategic Pivot
A conventional assessment answers the question it was asked. It ranks the networks, finds the underperformers, and recommends negotiation targets.
The payor mix analysis surfaced something more consequential.
The practice had substantial patient demand — no shortage of people wanting appointments. But a significant portion of that demand was concentrated in lower-reimbursing Medicaid plans. Which meant the strategic question was never which plans pay the most.
It was: how does this practice want to use the doctor and hygiene capacity it already has?
That reframe changes what a good outcome looks like. Negotiating a higher fee on a plan that is consuming chair time the practice cannot spare does not solve the problem. It optimizes the wrong variable.
The objective is not simply to increase patient volume. The objective is to ensure the practice’s available clinical capacity is being utilized in a way that supports appropriate patient care, stronger production, and the long-term financial goals of the practice.
The Finding That Stopped the Clock
Patient volume indicated the practice had enough demand to support roughly two full-time dentists.
But the data did not reconcile. The payor mix report reflected a single provider with approximately 4,500 patients. The production summary showed approximately 3,600 patients actually seen during the reporting period.
A gap of roughly 900 patients.
Most consultants would have moved past it. True active patient count and true provider capacity are the inputs every downstream recommendation depends on — network participation, new-patient acceptance, expansion decisions, plan termination timing. Build a strategy on a number that is off by 900 and every move inherits the error.
The recommendation was to reconcile the discrepancy before making a single network change.
The Strategic Fork
With capacity established as the governing constraint, the assessment laid out the decision the practice actually had to make — and did not make it for them:
Path A — Grow into the existing Medicaid population
Requires additional provider coverage and/or expanded clinical capacity. Viable, but it is a staffing and facilities decision before it is an insurance decision.
Path B — Hold capacity and change the mix
Limit new-patient acceptance under selected lower-reimbursing plans. Create access for higher-reimbursing PPO and non-insured patients. Evaluate terminating selected Medicaid plans only once sufficient replacement demand exists.
The sequencing in Path B matters more than the tactic. Terminate first and hope demand fills in, and the practice absorbs empty chair time it cannot afford. Build replacement demand first, and termination becomes a low-risk formality.
And before either path: maximize the productivity of the capacity already in place — comprehensive treatment discovery, case acceptance, recall and reactivation, hygiene utilization, and production per doctor chair hour. The cheapest revenue in any practice is the revenue already sitting in its own charts.
The Negotiation Approach
Fee negotiation was one instrument, not the strategy.
Each network was evaluated against four possible outcomes — maintain current participation, renegotiate, reroute through a rental network, or strategically modify the relationship — with every option weighed against reimbursement, patient access, and long-term practice goals.
Every negotiated schedule was then run through a Fee Schedule Comparison Matrix, which evaluates direct contracts, rental networks, and leased network opportunities side by side across the practice’s most frequently performed procedures.
Why that comparison exists
A network offers a 20% increase on a crown currently reimbursing at $600 — bringing it to $720. Attractive in isolation.
Run the same procedure through an alternative participation pathway and the reimbursement range becomes $840 to $1,000.
The direct offer was never the best available offer. It only looked like one because nothing was being compared to it. This is why networks are analyzed in combination rather than one carrier at a time — the question is never whether a single contract improved, but whether the portfolio is optimized.
Positioning the Fee Schedule
The assessment recommended maintaining the UCR fee schedule at no less than the NDAS 70th percentile.
Since late 2024, insurers can see the actual fees submitted on claims. A practice that consistently submits its discounted PPO fee instead of its full UCR is teaching every carrier that the lower number represents the true value of the service — and erasing the evidence it would need in any future negotiation.
A fee schedule is not a price list. It is the documentation of what your work is worth.
Playing the Next Board
The assessment also positioned the practice against a demographic shift already underway.
- Medicare Advantage enrollment grew from 19% of Medicare beneficiaries in 2007 to approximately 54% in 2024
- An estimated 35.7 million beneficiaries were expected to be enrolled by 2025
- The Medicare-eligible population is projected to exceed 93 million Americans by 2060
Patients aged 62 and older are among the fastest-growing segments transitioning into Medicare Advantage. A practice that understands how many of its current and future patients fall into that group can decide now whether MA-accessible networks belong in its long-term strategy — rather than reacting after the landscape has already changed, and after those patients have already gone somewhere that accepts their new plan.
The Outcome
A coordinated Game Plan with $63,000 in projected annual gains over a 6–8 month execution window — built not from a single negotiation, but from the combined effect of network participation strategy, fee schedule positioning, capacity utilization, and forward market positioning.
The plan was paired with required administrative team training, on the principle that a negotiated gain the front office does not know how to post, verify, or protect is a gain that quietly disappears within two quarters.
Strong negotiation creates the opportunity. Correct implementation is what keeps it.
The Takeaway
The practice asked what its plans were paying.
The answer that mattered was what its chairs were doing — and whether anyone had verified the numbers underneath the question.
