Did you know? A $1 increase in reimbursement for a single procedure could mean $5,000 more in annual revenue for your dental practice.
Imagine performing that procedure 20 times a day, five days a week, for 50 weeks a year. If your PPO fee schedule could be renegotiated to secure that extra dollar per procedure, you could bring in an additional $5,000 annually, assuming every procedure qualifies for the increase.
Now imagine finding similar opportunities across several procedure codes or identifying payments that fall below your contracted rates. The financial impact could be much greater.
That is why the American Dental Association recommends reviewing signed PPO agreements every year. Your review can help identify outdated reimbursement rates, questionable payment adjustments, costly contract terms, and networks that may no longer make financial sense. Here are 10 reasons to review your PPO contract annually.
1. Your PPO Fees May Be Falling Behind Rising Operating Costs
You signed your PPO contract in 2023 or 2024. Have your team’s salaries stayed the same since then? What about dental supplies, equipment, rent, and other everyday expenses? If these costs have gone up, why are you still accepting the same PPO fees?
When your operating costs rise, but reimbursements stay the same, each procedure leaves less money to cover your expenses. That is why it is worth revisiting your PPO fees.
You might think an extra dollar or two per procedure will not make much difference, but these small numbers tend to add up drastically.
2. Your Insurer May Not Be Paying Your Contracted PPO Rates
Did you know a claim can be marked as paid even when your practice may not have received the full amount allowed under its PPO fee schedule? In one payment-audit provider’s review of 2,399 claims at a single dental practice, 27% were identified as underpaid.
Sometimes, the insurer’s system may use an outdated fee schedule or fail to apply an agreed rate change correctly. Other payment differences may be valid under the patient’s plan, so it is important to check before assuming an error has occurred. That is why reviewing your PPO payments matters.
3. Your PPO Contract May Extend to Networks You Never Agreed to Join
You signed up with one PPO network, but did you know your contracted rates could also apply to patients covered by another network? This can happen when your agreement includes a network leasing or affiliated-carrier clause.
Network leasing clauses and affiliated-carrier clauses can allow other insurers or networks to access the discounted rates in your PPO agreement. This means your practice could be accepting lower fees for patients covered by networks you never directly contracted with.
But you can prevent such surprises by reviewing your PPO contract for network leasing and affiliated-carrier clauses. If your agreement allows it, you may be able to opt out of certain network arrangements or negotiate limits on which networks can access your contracted rates, helping you avoid extending your discounted fees further than you intended.
4. Your PPO Contract May Be Outdated While Payment Rules Keep Changing
Did you know insurance companies can update their provider manuals and claims processing policies without asking every dental practice to sign a new contract? These changes can affect how claims are processed and how much your practice gets reimbursed.
What this means is that the rates or payment rules your team expects may not always reflect the latest terms. For example, if an insurer updates its fee schedule or changes how it applies certain reimbursement rules, your practice could miss an opportunity to receive the correct payment or overlook a change that affects collections.
That is why reviewing your PPO agreement and the latest payer policies every year matters. It helps you spot changes early and understand how they affect your reimbursements.
5. Bundling and Downcoding May Be Reducing Your PPO Reimbursements
Did you know bundling and downcoding are among the most common dental insurance claim concerns reported to the ADA? An insurer may combine separate procedures for payment or reimburse a treatment using a lower-cost code than the one you submitted.
What could this cost your practice? Imagine 40 claims are incorrectly reduced by $30 each because of bundling or downcoding! That means missing out on $1,200 in reimbursement.
Reviewing your PPO agreement and the insurer’s latest processing policies can help you understand when these adjustments apply. You can then spot questionable payment decisions, investigate them, and appeal when appropriate.
6. Old Claims May Trigger Recoupments From Future PPO Payments
Imagine checking your insurance payments and finding that the insurer has suddenly deducted $2,000 to recover an alleged overpayment from an old claim. The original claim could be months or even years old, and the deduction could affect payment for an entirely different patient.
This is called a recoupment or offset, and your PPO contract may allow it. The ADA notes that recovery rights depend on your agreement and applicable state law. But you can prepare for these surprises by reviewing your PPO agreements every year for:
- How far back an insurer can recover payments,
- What notice it must provide, and
- How much time you have to dispute a deduction.
Knowing these terms before a recoupment happens can help you challenge questionable recoveries in time and protect your practice’s cash flow.
7. Your PPO Contract May Restrict What You Can Charge Patients
A patient has PPO insurance, so you expect the plan to cover the procedure. But what happens when you find out it doesn’t?
Even when a patient has insurance, certain services may be excluded or subject to specific plan rules. If you have not reviewed your contract and the applicable policies recently, you could miss these restrictions and quote a patient the wrong out-of-pocket cost.
That means you may end up writing off part of the fee or facing a billing dispute if you cannot collect what you expected. Reviewing your PPO agreements every year helps you check the rules for noncovered services and patient responsibility before they create problems.
8. PPO Payment Methods May Be Cutting Into Your Collections
The insurer pays your claim in full, but your practice still loses a slice of that payment. Why?
Virtual credit card payments can carry processing fees of around 2% to 5%, according to the ADA. If your practice processes $100,000 through fee-bearing virtual cards, that could mean $2,000 to $5,000 lost to fees.
Reviewing your PPO payment terms every year can help you spot these hidden costs and check whether better payment options are available.
9. Unexpected Insurance Costs May Be Damaging Patient Trust
Imagine a patient agreeing to treatment, believing their PPO plan will cover the cost, only to receive an unexpected bill later. Alternate benefits, bundling, and coverage limits can leave patients paying more than they expected.
They may feel frustrated, confused, or even question whether your practice was upfront about the charges. That loss of trust could cost you the patient, too.
Reviewing your PPO policies every year helps your team understand these rules, explain potential out-of-pocket costs before treatment, and give patients a clearer picture of what their insurance will cover.
10. Your PPO Network May No Longer Be Worth the Cost
A PPO network may bring new patients to your practice, but are those patients generating enough revenue to justify the cost of participating?
Contracted write-offs, underpayments, and the time your team spends chasing claims can eat into your earnings. Reviewing collections, patient volume, and administrative costs for each network can help you see whether the arrangement still makes financial sense.
Make Your Annual PPO Review Count
From outdated fee schedules and hidden payment fees to unexpected write-offs, your PPO agreements can affect more of your revenue than you realise. An annual review helps you spot these issues, identify opportunities to negotiate better terms, and protect your practice’s collections.
But knowing what to look for and what to do next can be complicated. That is where BEANbite comes in. We help dental practices review payment patterns, identify underpayments, investigate claim discrepancies, and improve billing processes so you can pursue every dollar your practice is rightfully owed.
Ready to Review Your PPO Agreements? Contact BEANbite today!
