What factors should I consider with respect to participation?

Dentists are asked to participate with an insurance carrier and provide services to insurer’s members at reduced allowances. In exchange, the insurance carrier lists providers’ names as participants, ostensibly to attract the insurer’s members into those practices. Participants are obligated to accept the insurer’s allowance as paid-in-full, less coinsurance and deductible. There are several factors to consider with respect to participating with an insurance carrier:

  1. What is your personal practice philosophy?
  2. How will your fees be impacted?
  3. Will the suggested increase in patient load offset the fee reduction?
  4. Do many businesses in your area cover their employees with dental insurance?
  5. Do most other dentists in your general geographic area participate?
  6. Does the carrier that you’re considering “Accept Assignment” wherein the patient can assign their checks directly to you, even if you do not participate?
  7. What percentage of your practice can involve insurance (with reduction in fees) and still allow you to pay expenses and make a reasonable profit?
  8. What does the insurance carrier expect of you?
  9. What are the Utilization Review requirements?
  10. Will you undergo a credentialing process? By whom? What is the process?
  11. What is the terminal provision of the contract that you are expected to sign? 
  12. Will you be required to permit insurance representatives to review/audit your office?
  13. Will you be required to accept the insurance carrier’s allowance for non-covered services?

Note: The ADA will review insurance carriers’ contracts and provide analysis. Simply send the contract electronically, as an attachment, to PDA staff and PDA will coordinate the analysis. For additional information, view Considerations for Participation.

Answer is informational only and not intended as legal advice. Answer may contain excerpts from
 The ADA Practical Guide to Frequently Asked Legal Questions.