Rules You Must Follow as a PPO Dentist

Have you thoroughly read your PPO contract? Do you know how many rules are included in your contract’s pages? Did you know that If you are a contracted member of a PPO plan, they have the right to audit your records?

In this episode, Gary and Naren discuss the importance of thoroughly understanding your PPO contract! Gary talks about why it’s essential to follow the rules if you are in a PPO plan. A small honest error could land you in prison, and you could lose your license! He also discusses how not choosing to participate in the PPO plans will eliminate all the complex layers of a PPO contract. Gary and Naren then share the story of Dr.Roy Shelburne. The respective podcast link is shared under resources.

If you are scared of losing patients, you can act proactively by introducing a digital marketing plan. Gary emphasizes how Ekwa Marketing has supported him in attracting quality patients throughout the years. If you would like to learn about how Ekwa Marketing can help your practice become thriving and profitable, you can visit, 

www.lessinsurancedependence.com/mastering-dental-marketing/

• 00:00:50 – Introduction to the episode
• 00:01:20 – Quick Announcement (Gary’s Thriving Dentist MBA Workshop – 9 Hours of CE)
• 00:04:01 – PPO rules and their layers of complexity
• 00:05:04 – Who do you think the PPO contract favors?
• 00:05:37 – Running a practice is complicated
• 00:06:46 – Dental profession’s contribution to infection control
• 00:07:49 – Do not bend the rules in the PPO contract because the stakes are high!
• 00:09:24 – Dr. Roy Shelburne’s story – A Prisoner Set Free
• 00:10:37 – If you are a contracted member of a PPO plan, they have the right to audit your records
• 00:11:38 – Gary provides examples for the above
• 00:14:58 – Protect your license
• 00:15:55 – Why aren’t dentists aware of all the rules in their PPO contract?
• 00:16:30 – Ignorance is no defense: Your license is on the line!
• 00:18:34 – The best alternative solution
• 00:18:51 – Follow the 6 steps to successfully reduce PPO plans

Naren, and I’m excited about that upcoming thriving dentist MBA. It’s one of my favourite workshops to give and I’m excited about it because of how practical it is. I’m also very excited about the live stream format. I think it’s the best of both worlds. Our attendees can attend from the comfort of their home or office and yet we’re doing it live. It’s not recorded we’re doing it live so that we can interact with our attendees so they can get the most out of it and hey if you’re interested in really mastering the business side of dentistry, come join us on June 21st, 22nd and 23rd. Three hours each night get nine hours of CE, I think you’ll enjoy it 

Absolutely Gary and I’m really looking forward to our topic today.  Rules you must follow as a PPO dentist I’m an entrepreneur and one of the things I love I live in Canada by the way I’m sure you all know that but one of the things I love about the us and Canada is it’s a free market, you know if you work hard government tries to give you an environment where you can succeed but unfortunately if you are a PPO dentist you have a lot of people to answer to. You have to answer to the IRS, you have to answer to all the other people who care about the health of the patient, the health of the employee, the safety of the employees and you have to answer to every single PPO company. As this is the less insurance dependence podcast Gary’s going to share his experience of things you need to pay attention to if you’re a PPO dentist. This way you know you are avoiding trouble and perhaps this will also think about the actual cost of having these relationships. It’s just not the write-offs it’s a lot more than that so Gary let’s jump in 

yeah Naren you know let’s recognize something now, you know I own my own business and have many for, for, many, many, years and there’s rules we have to follow you know there’s, there’s, rules and as there should be you know for our listeners in a healthcare environment there needs to be rules, you know for the safety of, of, our patients and, and, you and your team members. However, there’s a whole layer of complexity that dentists engage in when they sign a PPO contract, and doctors, I have a playful question to ask you. If this was a live audience, I would say hey guys I want you to participate with me here. How many of you have read your PPO contracts from start to finish, and Naren I can politely, I can confidently say that every time I’ve asked that question in an in-person audience, not a single hand has gone up, not a single hand has gone up

these are like hundreds of pages right this is not like a one page

Hundreds of pages, starting with, with little tiny you know eight-point text you know I’m referring to the text size, little tiny print hundreds of pages and by the way who do you think the contract favours?

the insurance company 

the insurance company

they probably paid like millions and millions of dollars to get that

they had an army of attorneys write that contract 

yeah 

And yet it, it, it, introduces many very detailed forms of compliance that must happen and, and, you know like I said, running a practice is, is, complicated, it’s complicated. We have to be HIPPA compliant 

yeah 

we all know the acronym HIPPA now we have to be HIPPA compliant, we have to be OSHA compliant we have to provide a safe work environment you know think about something as simple as sharps you know in the dental office, Naren, you know the needles  we’ve got to provide a safe place to dispose of those,

Yeah

  So we’re not getting you know needle sticks just among other things with, with, OSHA and then you know we have to be serious about infection control in the practice. I mean I’ve been in dentistry long enough to remember when infection control was an alcohol wipe, and I remember when dentists didn’t wear gloves and masks. I started in 1980. So that was quickly changing and really what, what, drove the infection control rules and regulations was the, the, aids epidemic Naren, when aids became you know an epidemic we had to provide safe environment you know for our patients and that’s really where we got to today with  you know having state of the art infection controls and you know what, I want to I want to kind of brag on our profession for just a minute Naren  and it’s very timely with what we’ve just been through with COVID but I think the dental profession has, has, earned a very high report card in providing safe environment regarding infection control for our patients

absolutely I have gone to my dentist so many times and you know I never got sick from there you know like ever so it’s just  

and it’s not that it you know there are things outside of our control but I think the fact that when you look at say dentistry, we had a foundation of, of, infection control that went back you know 30 years, 40 years  40 years and, and, you know we simply  made those even deeper you know during COVID and I think the end result  was that we provided as safe of environment as we possibly could for ourself for our team members and our patients and I think dentists should be  complimented  for that wasn’t easy and it incurred a lot of expense by the way much of which  the insurance companies didn’t help us with at all

Yeah

  When it comes to that expense. So, we have so many rules that have to be followed and, and, let’s, let’s, recognize. There’s a place for those rules but do we need another layer of complexity in your life being compliant with all the PPO plans and I want to be very, very, clear from a messaging standpoint. I am not suggesting in any way shape or form you should skirt those rules in the contract. I’m not suggesting that and the reason I’m not suggesting we bend the rules is the stakes are too high. If you end up inadvertently doing something in your practice that would make you non-compliant with your PPO plan, the ultimate risk could be the loss of your license, the loss. Now that is extreme but Naren have you ever heard the saying if it’s been done before it must be possible

yes 

and that’s very true in this case there have been dentists that have lost their license because of unfortunate situations that happen relative to compliance with their contracts.

can we get into that Gary because I think just to understand the kind of you know things they have to watch out for and pay attention to

Well, let’s get into some details and by the way we want to post a resource for you on this website. Many of you that listen to the lesson insurance dependence podcast also listen to the thriving dentist show but if you’re new if you don’t know about the thriving show that’s our flagship podcast.  Naren, would you ask the team to post a link it’ll be a link in the show notes that is an interview I did with Doctor Roy Shelburne, Roy Shelburne and, and, you need to hear Roy’s story, because I have his permission to tell what I’m about to tell. Roy was convicted of fraud in his practice and served prison time prison time and I’ll, I’ll, just leave it at that and now Roy is very transparent I have permission to say what I just said he’s a friend he’s a wonderful friend and you need to hear Roy’s story 

and it’s because again my understanding I spoke to Roy about this as well like you cannot say well somebody in my team did it, I didn’t know that’s not something that

ignorance is no defence there Roy, I’ll give you the details in that podcast episode so I won’t I, I, don’t want to show the share those outside the podcast episode but there was some fraud unintentionally committed in his practice, unintentional it was very, very, very, minor. Roy was made an example of my legal system and that’s sometimes what they do and he served prison time and I want you to listen to this. So, here’s what I’m talking about if any if you are a member a contractor member of a PPO plan that PPO plan has the right to come into your practice and audit your records

  Has that happened in your experience with your clients?

absolutely I’ve seen it happen many times among my clients and they can come into your practice now you know I remember when those audits used to be paper charts, they’re auditing paper charts well now they’re auditing electronic records

right 

but they have the right to audit your records 

you cannot stop them

  no, they can’t you cannot they have that right it’s in the contract. It’s somewhere in that multiple 100-page contract it’s in there. They have the right. Now you know that’s like you know having the IRS come in and sit next to you at your desk and audit your finances but

if you have 10 PPO plans that means you have 10 IRS coming in 

and much of what they find Naren is unintentional 

Right

unintentional fraud 

Humans make mistakes right, I mean like you put the wrong code you 

It’s unintentional yeah so for example we all know that most PPO plans have a six month wait. Let’s use exactly this has happened I won’t use any names and 

Yeah

this has happened it’s actually happened many times so in their hygiene appointment in order to be covered under the two hygiene appointments a year, there has to be six months in between. What happens if they come in five months and 29 days.

denied 

Denied, now here’s what’s happened in practice. We have an opening in the hygiene schedule the hygiene scheduling coordinator looks ahead to the next week and let’s say the opening is on Tuesday afternoon and so she looks at next Tuesday afternoon and says well maybe that time works for Gary let’s bring him in a week ahead let’s say it turns out we can see it this week, would you like to change your appointment. Let’s say he does and let’s say the patient has some savviness around this because sometimes they do, and the patient says oh but that’s not a six month wait. Hey, why don’t you just put on the claim form that I came in next Tuesday. Now that’s fraud.  It’s not Gray that’s

this is black and white fraud 

black and white fraud now let’s combine this. What’s the most dominant, dominant, personality type Naren?

S’s and C’s 

Yes, S, is the most dominant. 40 percent of the population are conflict avoiders. They will walk 100 miles around the conflict. So, let’s say your insurance coordinator is a high S, which by the way makes her very good at that job because she loves details and now her now the patient says oh just do this. Just change it what does she what could she do if she wasn’t strong enough to say no, I can’t do that. That would be fraud 

right 

and I cannot take the risk of my doctor’s dental license I won’t do that but a conflict avoider will say oh okay 

right 

Same thing about the patient at the end of the year like you know we’re, we’re, providing a procedure by the end of the year and then we discovered that they’ve used all their benefits and maybe let’s do it a different way. Let’s say the patient isn’t pushing this but let’s say your insurance coordinator thinks oh to help Betty 

yeah 

yeah, we did the treatment on, on, December 30th but I’m just going to because she’s already used her benefits. I’m going to say we did it on January 2nd. No nobody gets hurt with that do they 

yeah, that’s what they think 

I mean that’s what they think and Betty and then the office manager does that to help Betty

right 

it’s good natured it was not melas there was no personal gain attached to it 

yeah

we said fraud we always think that there’s some personal gain attached to it 

right 

There’s no personal gain attached to it. She’s just trying to do something to help the patient she’s trying to be helpful 

yeah 

you know 

have you seen this example happen Gary in your work with clients 

sadly many times I’ve seen it happen many times and, and, I’ve seen it caught in an audit you know when the when the  PPO plan can come in and do an audit and depending on the degree of it and depending on whether there’s other patterns or other things going on in the practice, it could it could result in a board complaint, it could result in in further action,  which could ultimately escalate to a point of a loss of licensure, and doctor nothing is more sacred for you to protect than your license, without your license you cannot practice dentistry 

right and you’re at the mercy of that auditor right if he’s having a bad day, he fought with his wife you know you’re not going to have that 

you’re at the mercy exactly. They may have got stuck in a traffic jam on the way to your office and they are on fire, you know and it could be it could even be deeper than that. You could have an insurance coordinator that doesn’t know what, what, what, they’re doing. They’re not skilled they’re not trained in that and they change codes 

yeah 

you know oh well the, the, this contract doesn’t pay for this contract doesn’t pay for direct composite fillings it only pays for amalgam we don’t do amalgam. So, to help the patient I’m just going to say we did a crown. Now that’s fraud that’s fraud and, and, the vast majority of the time doctor has no idea this stuff is going on 

Let’s talk about why that is the case, why do you notice that I mean I can guess. My answer is it’s such a complicated business 

It is another thing

you have thousands of people 

It is another thing

so, all these yeah 

How many doctors even know all the regulations? They don’t 

Right like you said they haven’t even read the agreement so you know 

How many, how many doctors naturally gravitate to courses on coding you know as part of their CE path none 

zero

yeah, but what I want to tell you is, I I’m going to show you a better way than, than, sitting in coding classes 

Right

So, what I want to share with you and this is the point that you need to take home from this, ignorance is no defence. So, when the auditor says doc, you’ve got many incidences here of date changes. I had no idea what was going on. That is no defence. Who’s responsible? Who whose license was the claim filled letter? The dentist’s 

the doctor, the dentist’s, yeah 

The dentist so ignorance is no defence ignorance is no defence, and sadly I’ve seen the, and, and, Roy will tell you his story, a prison time on that on what truly was a miniscule in the overall scheme of things was a minuscule, minuscule, financial impact 

Yeah, the scary thing to me is you are at the mercy of this one person, his mood, his agenda or her agenda and then you, you, are the one paying the price. 

So, you have two choices, doctor. One choice would be to go get a PhD in PPO compliance. Did anyone hear the sarcasm in my tone of voice on that and, and, I would politely suggest that you don’t do that. Do you really want to sit in, like Naren, have you ever been in traffic school? 

No, I haven’t 

oh, my goodness. I have not recently, I said not recently but I’ve had to go to traffic school and those eight hours of traffic school are, are, like one to me. So, I mean you do not want to get a PhD in PPO compliance. First of all, all of them are different. Imagine that you’ve got 20 PPO plans and you have 20 different sets of compliance. They’re similar but they’re different.  So that’s one alternative is getting a PHD, not just a masters the masters won’t get it you got to go for a PhD 

and you had to keep updating right because they keep changing their rules

Resources to Help You Resign From PPO Plans – Grab This Freebie!

Listen to Dr. Roy Shelburne’s Story – A Prisoner Set Free!

Become a RIDA Member