If you own a dental practice and wish to accept insurance, you will need to decide what sort of plan in which to participate. There are a variety of plans, each of which offers different advantages and imposes different duties upon the dentist. Fortunately, you can negotiate the contract terms with the insurers who offer these programs, and having an experienced attorney on your side can help you through this process.
Whether you are just now considering accepting dental insurance or you wish to renegotiate your existing plan, count on Mahan Dental Law to work for your best interests.
Understanding the Different Insurance Plans
Although not all dentists accept insurance, many do. While the dental practice benefits from having access to a larger pool of potential patients, the patients receive discounts and other advantages through their chosen insurer. These are only a few of the most popular insurance plans:
- PPO (Preferred Provider Organization): In this arrangement, the dentist agrees to discount their fees in return for joining an insurance network. This allows patients the flexibility they desire to choose the right dentist for them.
- HMO (Health Maintenance Organization): Dentists who participate in HMOs receive fixed monthly capitation payment for each enrolled patient. This is regardless of how many services they render to their patients.
- Indemnity Plans: With an indemnity plan, the patient will pay upfront for services and then receive partial reimbursement from their insurance company. Meanwhile, dentists set their own fees without concern for network restrictions.
- Point of service plans: These arrangements allow patients in a managed care dental plan to seek dental services from a provider that is out of their network. Benefits to the patient are reduced if the provider is out of network.
Considerations for Common Insurance Terms
Regardless of which type of insurance plan you choose to accept, you can and should negotiate the terms with the provider so you can get the best deal that protects your bottom line. These are some considerations to keep in mind for the most common terms you will encounter:
Indemnification and hold harmless clauses
These terms require the dentist to reimburse the insurer for losses that arise out of the dentist’s actions. Although insurers prefer this clause so they don’t have to pay for a dentist’s malpractice, the language could be overly broad. The insurer may be partially responsible for the malpractice due to referral restrictions, for example, but the dentist might be assuming all of the risk by agreeing to the indemnification clause.
Recoupment
In the event the insurance company pays the dentist for more than it is obligated to under the insurance contract, they have the right to notify the dentist and request that the excess money be returned. But the contract should make it clear whether the dentist has any duty to identify such errors and notify the insurer. Also, there should be time limits and procedures for challenging the insurer’s overpayment determination.
Automatic renewal
Insurers typically prefer including automatic renewal clauses so the dentist will keep giving them business. But the dentist needs to have the right to terminate the insurance contract if it is not serving their interests, and ideally with minimal or no penalties. Easy termination with no explanation required and with no extra fees would be the best outcome.
Plan participation clause
The insurer will attempt to obligate the dentist to participate in its insurance plans or products, but the dentist may want to pick and choose among them. The dentist should review all insurance plans and programs with their attorney to ensure they are best suited to their practice.
Discounts to patients
For PPOs, the dentist is agreeing to discount the cost of their services for the benefit of having access to the insurer’s customers. But does this truly offer an advantage to the dentist? How many potential customers will this yield, and will the insurer specifically direct or refer their customers to the dental practice?
Terminating an Insurance Agreement
The decision to terminate your existing insurance contract is one that your practice will have to make as a matter of business. However, you should not make this decision lightly, and it’s imperative that you closely read your policy to determine if there are any legal or financial ramifications for doing so. An attorney can help with the following:
- Reviewing the terms of your contract to determine the steps you must take for terminating your agreement, and whether there are any clauses requiring payment of an early termination fee
- Examining your relationship with the insurance company to help you decide whether you may have grounds to terminate, such as a breach of the contract on the part of the insurer
- Checking to see if your dental practice must give advance notice, how much notice you must give, and then providing the notice in writing to the appropriate individual or department
- Providing ample and sufficient notice to your patients (usually 6-12 months) that their insurance will no longer be accepted once the contract is terminated
- Notifying your staff about the transition and training them to properly adjust to it, for instance by knowing how to field commonly asked patient questions
- Assisting your patients with the change, including by recommending other insurance plans that you already accept or helping them establish payment plans with your office
- Helping your practice select a new policy or provider to replace the old one
How Our Team Will Assist With Your Insurance Contracts
Retaining an attorney will affect your negotiations with insurance providers and, ultimately, the language of the contract that you sign. Mahan Dental Law can help you by:
- Explaining the details of the insurance plans that you are considering and what they may mean for your practice
- Helping you decide on a plan that best fits the needs, objectives, and interests of your practice
- Explaining various contractual terms, provisions, clauses, and conditions like those above
- Negotiating for the most advantageous terms so you receive the benefit of the deal
- Discussing the legal consequences of the insurance contract, including breaches of the agreement
- Helping you decide whether to offer your patients any alternatives to insurance, like payment plans
- If necessary, litigating or defending you in litigation, or representing you in alternative dispute resolution (ADR), with your insurance company
Contact Our Nationwide Dental Insurance Contracts Attorney
Patients and dentists alike benefit from dental insurance, but you should carefully review and negotiate the terms of your contract before you sign. Understanding what insurance contracts mean for your practice is essential to making the best business decision. It’s also vital to your financial well-being that you have legal counsel ready to defend your interests in court or ADR if necessary.
That’s where our law firm comes in. For all your legal needs concerning dental insurance, call or contact Mahan Dental Law today.
