Helping Your Practice Grow With Less Insurance Dependence

In this article, Kelly Fox shares practical strategies for dental practice owners looking to reduce insurance dependence. Whether you're at the beginning of your journey or well on your way, these insights will help you take meaningful next steps.

So to start, what inspired your focus on helping dental practices grow with less insurance involvement?

So I mean, this has been a journey for me over many, many years. I grew up as a dental team member working both in insurance and network practices and in really boutique-y fee for service. So just from the dental team member standpoint, I’ve seen both sides, and there are definitely good points about both, right? But as the years have gone on, and you know, now going into 2026, it’s becoming increasingly more challenging for in-network practices to be profitable because, right, as everyone knows, the fees have not increased relative to the cost of doing business and the cost of living for patients, et cetera, et cetera. And teams are becoming more challenged than ever because the dental insurance companies keep moving the goalposts, and just when we think we have it all figured out, they sort of change the rules of the game again.

And so we constantly feel like we’re chasing our tails. So I’m really passionate about helping practices figure out where do they belong in that landscape. I don’t think every single practice should be outta network. I don’t think that’s reasonable for patients. I think there’s a certain percentage of patients in this country today that still depend very much on in-network benefits. So I think there’s a middle ground somewhere. So my goal is to always figure out, like, where does each individual practice land in that landscape and what can we do to help them practice where they belong?

Kelly’s Story

Look for: lower profits, overbooked hygiene with little treatment, and rising write-offs.

Patients may show up for free cleanings, but delay real care.

Admin costs from managing confusing insurance rules can eat away at profits.

Amazing. And I think that gives a helpful background about sets the stage for our next key points of this episode. And now let’s move into something many doctors struggle with. What are the most common signs that a PPO plan is no longer helping a practice grow?

So I think when you’re, when, and I think most doctors, especially near the end of a calendar year, they’re becoming keenly aware of how profitable they were in a particular year. Many doctors unfortunately don’t mind their numbers all year long as they should, but this time of year in particular they’re more aware. The challenges, practice owners are not getting to keep as much of the revenue, as much of the profit that they’re generating as they have in years past. Yeah, seeing a big decline in that. And so that’s a huge red flag. If your hygiene schedule is booked many, many months out, but you’re not really generating as much productive dentistry as you were, that probably means that you have some of these lower reimbursement plans where the patients are great about utilizing their preventative care benefits because those are paid for a lot of those patients at a hundred percent.

So a lot of those patients are really meticulous. They do show up for their two free hygiene visits every year, but they’re not super motivated to do anything else. And so now the hygiene chairs get really booked out, super bogged down, and it shows in the overall profitability. It also makes it hard to get perhaps more motivated patients in for hygiene. So it becomes a vicious cycle. So that’s one big symptom, right? Another one is really looking at your write-offs and seeing how painful it is because so many practices have gotten good at understanding that they have to raise their UCR fees, even if most of their patients are in network. So the spread is becoming so vast between their usual and customary and their contracted fees. And thinking about that, if you’re writing off 35, 40, $50,000 a month, if you spent that amount of money on marketing, what would you have, right?

We talk about this all the time. So that’s a problem. That’s another big sign that something might not be right. When patients are constantly confused about their benefits because, as I said a few minutes ago, so many of the insurance companies, the policies are changing year over year. Exclusions are changing, waiting periods are changing. And so the patients, just when the patients feel like they understood their benefits, sometimes it changes again. And then we find our administrative team, when you look at the cost, Lester, in practices that are participating with all of the majors, and they’re in umbrellas, right? So now it gets super complicated to manage these umbrellas, and they’re in whatever in their region, unions and locals and self-insured and all of those. It is the administrative cost now of trying to understand these plans, enter these plans properly into your pmms, do eligibility, verify, educate the patient, and inform the patient about their patient responsibility. When you really look, practice owners, at the cost, the administrative cost, and then you combine that with the write-offs, it’s abundantly clear that you’re losing money and you are, the handful of plans that you participate with, or maybe even it’s two or three plans now that you participate with that have decent benefits and slightly more motivated patients, and your fee for service patients, they’re really carrying the profit for your entire practice. It doesn’t make any sense.

Signs a PPO Plan is Hurting Your Practice

Yeah, great insight. I think those common signs is basically any, it’s easy to understand if you are losing money or actually if you’re not doing well in your practice. So I think if you lean into those signs, you should be able to take a wise decision on that. Now, once the doctor sees that this is not working, then the next step is basically the team mindset, right? Now, how can the doctor and the team shift from an insurance mindset to a patient mindset?

So I think, you know, ask yourself the question, are you currently and consistently delivering the same exact patient experience today that you would deliver in 12 months from now if you were out of network? And if you are not already living it as if it were true, you’re not ready because it’s a big leap, and you’ve gotta be able to exceed patient expectations in every single way. So it does require a lot of honest self-reflection from the practice owner, first things first, and any and all other doctors on the team, and then of course the entire dental team to say, is this really the best we have to offer? And if we haven’t honed the craft of that, we’re not ready. So it begins with that. Next, I guess sort of in tandem to that, have you evaluated your practice reputation both online and off?

So, you know, do you get patients every week standing at the admin counter that are upset? If the answer is yes, your practice reputation is not where it needs to be to go out of network. If your Google reviews are 4.6 or 4.7, you’re probably not ready. So these are considerations that have to be made before we even begin the process of training to go out. First we have to figure out, are we capable? And that’s a tough question, but you’ve gotta be honest, right? And then so now let’s dive into the deep details. I mentioned it before, how booked out is your hygiene? If I just started working with a practice here in my region in the northeast, hygiene, there are no hygiene appointments until November of 2027. Literally none, not one unit of open time for 11 months.

Shifting from Insurance Mindset to Patient Mindset

They are beyond ready to go. Then they have 4.9 Google reviews, they’re beyond ready. So we’re gonna begin helping them on that journey. Next is if a non-emergency new patient called today. When would they get in? If a non-emergency new patient cannot get into your ideal new patient scheduling, which in some practices is with the doctor and some practices is with the hygienist, we could do a whole nother podcast on that. But if they call today, would they get in within seven working days or less at a time that they’re satisfied with and that you would consider your ideal new patient scheduling? If the answer is no and it’s consistently no, you probably have more patients than you can realistically accommodate, and your profits are low. So it’s time to consider. And then last but not least, and this is one that I think everybody misses, Lester, so I really want the listeners to focus on this and take note of this, meticulously tracking your new patient referral source for 12 months or more.

And if you have not done that, I don’t care if you hit all of the other marks, you’re not ready because we cannot really judge how much of your new patient flow is coming from insurance. And we can’t make a reliable plan to not have you have a tremendous die off in revenue when you go out. So you’ve gotta do that for 12 months or more. And that should be a number one training thing. Doctors listening, any team members listening, administrators, you’ve gotta capture that in the new patient phone call and put it right in the pms at that moment so that there’s no way it can get missed. And then we have to track that exactly.

Yeah. I think those are like the foundations. If you don’t have the foundations, of course you can’t move forward. It’s gonna tremble down. So correct. So now what skills or systems help the team increase care acceptance in a fee for service model?

So it’s being totally patient centered and again making sure that you’ve mastered the art of not just the new patient experience. We spend a lot of time in general in our profession focusing on that, but I like to call it the every patient experience. And is every patient experience remarkable in the very best of ways? And that includes when they call your office and they try to schedule online. Is that even possible? When they have a checkout, do they have to wait in line to check out like they’re at Costco? What is the full experience to be a patient in your office? And when you really dial in on that and you train your team on critiquing what makes it stellar and remarkable in every way, that helps them. It helps them have the confidence to wanna provide better customer service. It helps them perhaps be more willing to speak in a patient-centric way. Sometimes we call that scripting. Team members tend to have terrible aversion to scripting, but we always like to say scripts are not for you doctors and team members, they’re actually for your patients. So learning how to speak about everything in terms of benefits and making each and every patient feel like the only thing on your mind while they’re in your practice or on the phone in your practice is them.

4 Signs You Might Be Ready to Go Out-of-Network

Yeah. Yeah. I think now, once you set case acceptance, it connects right to communication. Just before you mentioned scripting, now how can dental teams explain insurance changes to patients in a simple and calm way that builds trust?

So, you know, I think that it’s important that you know your region, right? And so as a practice coach, I’m always gonna say work with an advisor, not chatGPT. And there are so many amazing coaches and advisors in this country, but there are regional specificities. And something that I, you know, right now I’m in Midtown Manhattan, and with all due respect, I have amazing coach friends and colleagues in the Midwest and in the Pacific Northwest, the things that they say do not work in Midtown Manhattan and vice versa. And so you really need to know your audience before you start to just come up with some generic scripting. You need to understand the pain point. And if you’ve been recording your phone calls, which I hope all of you have through whatever service you’re using, and you’ve been doing training on those phone calls like all other major businesses do when they record them, you’ve learned what the pain points of patients are when they’re calling and they’re asking about insurance.

And so that’s really what your scripts need to speak to. Your scripts need to speak to what are the pain points in your particular practice. With all due respect, I don’t care what 3000 dentists in a national Facebook group page said because that might not be what’s happening in your specific ecosystem. So dialing in on the scripts that matter, making them patient-centric, speaking to your audience, not anybody else’s, and doing it from the heart, knowing that ultimately being in network with these plans, if you’ve gone through the analysis process that we talked about, Lester, your entire team should be privy to those findings, by the way. So they should really understand that we’re not serving our patients at the highest level when we have to tell a new patient that they can’t get in for three weeks, when we have to tell a returning patient that has never missed an appointment that they can’t have a hygiene appointment for seven months because our chairs are filled with $39 pro fees. When the team has visibility on all of that, they can really start to move with heart and intention, and the scripts become quite natural. It just becomes how we feel and we mean it. So the patients aren’t feeling like we’re trying to upsell them anything. The team isn’t feeling like we’re scamming. It just all starts to make sense. And again, if you’ve gone back to those first steps of analyzing and being honest with yourself, the full circle is not that difficult to achieve.

Communicating Insurance Changes to Patients

Exactly. Exactly. Now, as you know, I think for practice, right, to move away from heavy insurance use, what are the first few steps that they could take? Probably when this episode is going live in 2026, what do you think they should be doing?

So I think there are different philosophies for sure on how to go outta network, but for me, a big driver is not how many patients you have on a particular plan, unless you’re DMHO. And I’m really talking about the steps to go outta network with PPO right now. DMO is a little bit different. So if your PPO, I don’t really care the number of patients in your database that are attached to Delta Dental, I care the utilization. So those are very different reports. And so we wanna figure out in a 12 month or an 18 month period, again, different schools of thought, we wanna just know annual revenue or do we wanna know active patients, because zero to 18 months are your active patients. So two different ways that you can approach that. What is the total amount of revenue?

Let’s just say Delta, the big bad cookie man of all of them, what’s the total amount of revenue that came from all of your Delta Dental patients from the insurance side and the patient side in that window of time? And so now we know that’s the magic number that if they all decide to jump ship, what are we trying to replace, right? And then there’s a math equation. So if we know that those fees, and I’m just gonna give generic numbers right now, these numbers might not be realistic for each individual practice. But let’s say that that particular plan that we’re analyzing, the entirety of all the groups, it’s an average of a 35% discount off of your UCR. There is now a math equation of how many patients you need to keep to just maintain versus how many you need to keep to grow, or what are you willing to do and what will you have to do to replace them if you lose more than what you calculated.

Right. Alright. So it’s, there’s a lot of soft skills and EQ skills on being honest with ourselves and improving the customer service experience and really being willing to do whatever it takes on the relationship side. But it’s also, you know, it’s pretty strategic and mathematical. And if you move through this strictly with emotion, ’cause unfortunately I’ve met so many practice owners that did this very emotionally without good guidance, and the results can be pretty catastrophic depending on where you’re practicing. So I don’t advise just jumping on the hashtag trend, right. I think a lot of you guys know that hashtag that’s going around now. Be a little bit more. And by the way, I do, if you feel like you should be out, you should, but don’t do it strictly emotion based. You’ve got to be more resourceful than that and more methodical than that if you wanna win this game and really grow your business in all of the best ways possible.

First Steps for Leaving Insurance

Exactly. Exactly. I mean, Kelly, you’ve been sharing a lot of nuggets here in this episode, and one of the best ways, I think one of our listeners would love to reach out to you. What is the best way that they can reach out to you and get some advice?

Sure. Well, I love to meet as many people as I can. And the best way for me to do that is through something that I call the complimentary 30 minute coaching call. I sometimes call it Ask Kelly the coach anything. So if you go to my website, which is smile potential smile potential.com, that is the best way. You can click that link on there for 30 minute coaching call. You can also find me on Instagram and Facebook under the Smile potential name. And then I also have my personal page, which is Kelly the dental coach on Instagram. So I would love for your listeners to follow me there and see some of our tips and pearls that we’re giving out there. We’re at a lot of events, mostly in the northeast, but sometimes outside of our region. So I’d love to meet people in person and doctors and team members. If anybody has a question, a deep dive on something that we talked about today or maybe something that I missed and we didn’t cover, I’m happy to share as much knowledge as I can. So go on my website, www.smilepotential.com, click that, schedule a

Exactly. Amazing. I mean, if anyone listening in, if you still can’t find out or find the link, you can also look on our show notes on this episode website. And you can basically access the key details of this episode and the link to consult Kelly for more information. Kelly,