The term “in-network” is defined as health care facilities – hospitals, doctors, dentists, specialists, pharmacies –
that have an agreement with insurance companies to provide medical care to their insured members at a discounted rate. The rate is agreed upon by the health care provider. Patients will typically pay less with an in-network provider. At the time patients receive care, they pay what is referred to as a co-pay for covered health care services when their provider is in-network. If they choose to use an out-of-network provider, there are no co-pays, but they will pay more for the service.
Patients need to do the following to verify if your dental practice is in or out of their network:
- review their insurance company’s website
- call their dental office
- call their insurance provider or agent
If your dental office is out-of-network for them, there is not a contract between you as their service provider and their insurance company, and as a result, the patient will pay more out of their own pocket or have to pay the total amount of the service provided.
When prospective patients compare dental practices in their community for dental services, if your practice is in-network, it is most likely patients will make the decision to have you complete their treatment in order to save money. Also, the insurance companies may refer patients to your practice for service as well. Once your practice is declared in-network or a participating provider with one or several insurance companies, you can add their plans to your website as well as on social media sites. This is sure to spread the word and attract new patients to your dental practice.
How to Become In-Network
In order to become a member of a network, you must have a contract with the health insurance company or companies. Today’s health insurance plans consist of managed-care such as HMOs, PPOs, and POS plans. This means the insurance company has a list of dentists and facilities from which your patients can choose for their treatment. The list is referred to as the provider network. These plans usually are more affordable than fee-for-service plans; however, they do limit the patients’ freedom to choose their medical providers.
Health insurance companies determine who they contract with based on your discount as a provider and how available your services are to customers. Your dental educational background and board certification are also considered to become in-network, and once your dental practice is in a network, you agree to follow the plan’s rules.
Health Maintenance Organization (HMO)
An HMO is a health insurance plan that has a low co-pay and no deductibles or coinsurance. While there is less freedom for your patients to choose providers, the fees are often lower because they offer a large pool of patients who can’t go outside the network. HMO providers can offer a larger discount. The main rule for your practice and patients is to stay within the network.
Preferred Provider Organization (PPO)
A PPO health insurance plan offers patients the option of visiting providers outside the network. The only reason to go outside the plan is if your patient or yourself feels the best care can be found outside the network. The downside to this is your patients will probably pay a higher price (copays, deductibles, and coinsurance) than if they had stayed inside the network.
Provider Sponsored Organization (PSO)
A PSO is an organization for managed care that accepts full risk for beneficiary lives. They receive a fixed monthly payment to provide the care for Medicare beneficiaries. A PSO is required to supply all medical services required by Medicare Law primarily through its network.
Getting There With Credentialing
In order to become in-network, you enroll with the company or companies you want to be in-network with. The next process with each company you have to complete is called the credentialing process. This simply means you fill out an application, but the process is anything but simple. A single wrong answer or missed question means you must start over because the document cannot be amended. This application form takes 40 hours to complete, and if you start the process, you must complete it. Most dental practices that try to take on this process alone are very overwhelmed. Especially filling out multiple forms for multiple companies.
Attempting to handle the process of becoming credentialed can strain the time and energy of the team members of your dental practice. Their time and energy are usually better spent on patients and operating the dental practice. Most dental care practices prefer to hire someone and work with them to become credentialed.
Now is a great time to begin the process as the year 2022 is just beginning.
After 30 years of experience, Strategic Practice Solutions and PPO Negotiation Solutions are experts at handling PPO negotiation and participation optimization. They outperform any other PPO negotiator. Their process saves you time and increases new patient prospects. Schedule your complimentary assessment and/or consultation today!