Can You Negotiate Dental Fees With Your Insurance?
The short answer is yes.
In many cases, dental PPO fees can be negotiated. However, one of the biggest misconceptions among dentists is that negotiating fees is as simple as calling an insurance company and asking for more money. In reality, successful negotiations often require data, strategy, timing, and a thorough understanding of how dental insurance contracts work.
Over the past 14 years, our team at Apex Reimbursement Specialists has negotiated more than $1 billion in PPO revenue and worked with nearly 5,000 dental practices across the country. During that time, we’ve learned that many dentists are leaving money on the table—not because they’re poor clinicians, but because they don’t fully understand how their insurance contracts, fee schedules, and network relationships impact reimbursement.
Let’s take a closer look at what dentists should know about PPO fee negotiations and how they can determine whether an opportunity exists within their own practice.
The Biggest Misconception About PPO Fee Negotiations
Many dentists believe one of two things:
- Insurance companies never negotiate.
- If they do negotiate, all you have to do is ask.
Neither is entirely true.
Some insurance companies are willing to negotiate under the right circumstances. Others rarely negotiate. More importantly, insurance companies typically want a reason to increase your fees. They want to understand the value your practice brings to their network.
Questions they may consider include:
- How much production do you generate?
- How many patients are utilizing your practice?
- What procedures are being performed?
- Are you providing access in an underserved market?
- Are you a specialist with unique services?
- How do your fees compare to others in the area?
In other words, successful negotiations are often driven by data—not emotion.
Before You Negotiate, Make Sure You’re Not Making These Mistakes
One of the first things we review when evaluating a practice is whether the foundation is set up correctly.
Surprisingly, many practices have incorrect fee schedules entered into their practice management software.
We’ve seen offices enter insurance company fees rather than their own UCR (Usual, Customary, and Reasonable) fees. This can create reimbursement issues because insurance companies generally pay the lesser of the contracted fee schedule or the fee submitted by the practice.
Your UCR fees should generally reflect the fees you wish to charge for your services. If those fees are outdated or entered incorrectly, you may be limiting your reimbursement before negotiations even begin.
Other common issues include:
- Participating in networks that are not producing patients
- Failing to review EOBs consistently
- Not understanding how the practice is contracted
- Missing opportunities created by network leasing arrangements
- Assuming their current fees are competitive simply because they’ve had them for years
Not All PPO Contracts Are Created Equal
One of the most overlooked aspects of dental insurance is understanding how a practice is actually contracted.
Many dentists assume they have a direct contract with a carrier when they are actually accessing that carrier through a third-party leasing arrangement.
These relationships can significantly impact reimbursement.
In some situations, we’ve found that an indirect contract pays more than a direct contract. In others, the opposite is true.
In fact, we’ve encountered situations where two dentists working in the same building had entirely different fee schedules with the same insurance company.
One dentist may be receiving significantly higher reimbursement than another despite offering similar services in the same market.
The point is simple: assumptions can be expensive.
What Gives a Dental Practice Negotiating Leverage?
Every insurance company evaluates fee requests differently, but several factors consistently influence negotiations.
Production Volume
Insurance companies pay attention to utilization.
If a practice generates significant production through a carrier, that carrier may be more willing to evaluate fee increases because they want to maintain the relationship.
Geography
Location matters.
For example, if a practice serves a rural area where patients have limited access to dental care, the insurance company may place additional value on maintaining that provider relationship.
Specialty Services
Specialists often have greater negotiating leverage because they provide services that may not be readily available elsewhere.
Time Since Last Review
One of the biggest opportunities we see occurs when a practice hasn’t reviewed its fees in years.
If a dentist has been participating with a carrier for a long time and has never requested a review, there is a good chance their reimbursement no longer reflects current market conditions.
A Real-World Example
One general dentistry practice in Maryland came to us because they felt their reimbursement rates were not keeping pace with the value they were providing.
After reviewing their contracts, fee schedules, and network participation, we identified several opportunities for improvement.
Our team evaluated how the practice was contracted, determined which networks made the most strategic sense, and negotiated with multiple carriers on their behalf.
The result?
An average increase of approximately 39.5% across the carriers we negotiated.
That’s a meaningful increase in top-line revenue without adding operatories, hiring associates, or increasing patient volume.
Can You Negotiate PPO Fees Yourself?
Absolutely.
Just like you can mow your own lawn.
Most homeowners are perfectly capable of mowing their lawn. Yet many choose to hire a professional because they recognize the value of having someone who does it every day, has the right tools, and can often achieve a better result while freeing up their time for other priorities.
PPO fee negotiations are similar.
A dentist or office manager can certainly contact an insurance company and request a fee review. However, successful negotiations often require benchmarking data, contract analysis, production analysis, persistence, and an understanding of how different carriers evaluate requests.
More importantly, every hour spent negotiating with insurance companies is an hour not spent focusing on patient care, scheduling, collections, treatment acceptance, staff management, and practice growth.
One of the advantages our team brings to the table is perspective.
Over the past 14 years, we’ve negotiated more than $1 billion in PPO revenue and worked with nearly 5,000 dental practices. That experience provides access to data and trends that individual practices simply don’t have.
Could you negotiate yourself?
Yes.
The better question is whether you have the time, resources, and information necessary to maximize the opportunity.
Insurance Companies Are Not the Enemy
This may be an unpopular opinion, but I don’t believe insurance companies are inherently bad.
Many dentists feel insurance companies undervalue the services they provide. In some cases, that criticism is justified.
However, insurance companies also serve another purpose: they can be a powerful marketing tool.
Let’s say a local school system offers Delta Dental to its employees.
If your practice participates with Delta Dental and actively markets that fact, you may attract patients who are specifically searching for an in-network provider.
The practice next door that doesn’t participate may never have the opportunity to serve those patients.
Insurance participation should be viewed strategically.
The goal isn’t to be in every network.
The goal is to participate in the networks that make sense for your practice, your market, and your long-term objectives.
Sometimes the Best Advice Is Not to Negotiate
One thing we’ve learned over the years is that negotiation is not always the right answer.
There are situations where we advise dentists to wait.
For example:
- The carrier may have a contract provision preventing negotiations until a future date.
- An acquisition may be planned in the near future.
- The practice may only participate with carriers that historically do not negotiate.
- The timing may simply not be favorable.
There are also situations where we tell a dentist we don’t believe we can provide enough value to justify moving forward.
Our goal is not to negotiate for the sake of negotiating.
Our goal is to help practices make informed business decisions.
How Much Can Fee Negotiations Impact Revenue?
Every situation is different, and results vary.
However, across thousands of negotiations over the past 14 years, our average increases have generally fallen within the 8% to 12% range on highly utilized procedure codes.
Think about what that means.
A practice may be able to increase revenue without:
- Adding patients
- Adding providers
- Expanding hours
- Purchasing equipment
- Opening additional locations
In many cases, improving reimbursement is one of the most efficient ways to increase practice revenue.
Final Thoughts: Don’t Delay
If you’re a dentist and you do only one thing after reading this article, don’t delay.
Analysis paralysis keeps many practices stuck with reimbursement rates they established years ago.
You don’t have to make a decision today.
You don’t have to terminate networks.
You don’t have to overhaul your practice.
But you should understand your contracts, review your fee schedules, and determine whether opportunities exist.
The reality is simple: if you never evaluate your PPO participation and reimbursement, you’ll continue operating under the same fee schedules you have today.
And you may never discover what was possible.
