Can PPO Plans Set Fees for UnCovered Services?

In this episode of the Less Insurance Dependence Podcast, Gary and Naren discuss a pressing question for many dentists: Can PPO plans legally set fees for services they don’t even cover? In 43 states, the answer is no.

Gary breaks down the history, state-by-state legislation, and how many practice owners are still being limited by outdated contract terms without even realizing it. If you’re offering high-value services like implants, veneers, or cosmetic dentistry, this episode is a must-listen, especially if you’re practicing in one of the seven states still allowing PPO fee control over non-covered services.

• Understanding PPO Fee Control
  Why PPOs setting fees for uncovered services has long been problematic, and how legislation has changed that in most states.
  
• The Power of Knowing Your Rights
  Many dentists don’t realize they can charge their full UCR fees for non-covered services in 43 states. This lack of awareness is costing them thousands.
  
• Which States Are Still Behind
  Only 7 states still allow PPO plans to set fees for non-covered services: Delaware, Hawaii, Maine, Michigan, New York, South Carolina, and Tennessee.
  
• What Dentists Can Do Now
  How to identify uncovered services, adjust fees accordingly, and if you’re in one of the 7 restricted states, what actions you can take to support legislation change.

• 00:12 – Introduction
  • Gary introduces the episode topic and why it’s a critical issue for practice profitability.
  • Brief overview of how insurance companies impact treatment fees—even on services they don’t cover.
    
• 01:28 – Can PPOs Set Fees for Uncovered Services?
  • Explanation of what “uncovered services” are and how PPOs attempt to control fees for them.
  • Why is this practice seen as unfair and limiting to providers?
    
• 03:06 – Understanding State-by-State PPO Legislation
  • A look at how 43 states have passed laws prohibiting PPOs from setting fees for non-covered services.
  • Why are these state-level changes a big opportunity for practice owners?
    
• 05:06 – 7 States Where Fee Control Still Exists
  • List of states that still allow fee control: Delaware, Hawaii, Maine, Michigan, New York, South Carolina, and Tennessee.
  • Discussion about legislative efforts and what dentists in those states can do.
    
• 08:29 – How to Adjust Your Fees for Uncovered Services
  • Encouragement to review contracts and update fee schedules where legally allowed.
  • Why cosmetic, implant, and elective procedures should be priced at UCR rates.
    
• 09:07 – Real Case Study: From $600 to $1,800 per Veneer
  • Story of a dentist tripling revenue by removing unnecessary fee restrictions.
  • How patients responded positively when the value was clearly communicated.
    
• 12:59 – How to Push for Change in Your State
  • Tips on contacting local dental associations and legislators.
  • The importance of collective advocacy in shifting outdated insurance regulations.
    
• 16:13 – Closing Thoughts
  • Long-term impact of reclaiming control over uncovered services pricing.
  • Hidden revenue potential waiting to be unlocked in most practices.

Why should an insurance company be able to set a fee… on a service they don’t even cover?

They have no right, in my opinion, to set that fee. And I’m happy to see that 43 states are now free from that constraint.