What should you gather for a dental PPO contract review?
Start a dental PPO contract review with the agreement, its fee schedule, and a few EOBs you can compare with that schedule. Keep one row per agreement. If you don't have a document or can't confirm which schedule applies, mark it unknown and request it.
| Worksheet field | What to attach or confirm |
|---|---|
| Practice and agreement | The provider, location, and contract being reviewed |
| Network participation | Written confirmation of the networks involved |
| Fee schedule | The schedule identifier, effective date, and document |
| Dates to act on | Review, notice, filing, and appeal terms in the applicable documents |
| Claim example | The billed code, EOB allowance, and schedule amount you expected |
| Open question | A named contact, the request sent, and the follow-up date |
For a fictional example, suppose the schedule you're checking lists $900 for a procedure and an EOB lists an $850 allowance. Record the $50 difference and ask which schedule and processing provision the payer applied. Don't call the difference recoverable revenue until you've confirmed that the $900 schedule applies to that claim.
Bring unresolved contract terms to the person qualified to review your agreement. Use the adjustment posting guide to keep the ledger explanation tied to the EOB while the question is open.
Which networks are you actually in?
You might be in networks you never signed up for. One PPO contract can put you in-network with several other carriers through leasing, and when a claim comes in, the carrier can process it on the lowest fee schedule it has access to. Line by line, on the same claim.
That's why EOBs come back at numbers nobody expected. One office manager told us she has a routine for it. The wrong fee schedule is attached, the math doesn't match, and somebody posts an adjustment to make it agree.
You can't negotiate a contract you can't see. So pull every contract you've signed, then pull every network you appear in. Those two lists won't match.
Leasing is why. Sign with one plan and it can put you in-network with a handful of other carriers, sharing your contracted rates with them. Some contracts allow this without asking you again, which is where the term silent PPO comes from. Veritas Dental Resources has a useful breakdown of umbrella networks, stacking and hidden contracts, and Burkhart covers how leasing works alongside negotiation.
Your third-party administrator affiliations matter too, and they're easy to miss because you never signed anything with the TPA directly.
Practical version: call each carrier and ask which networks your NPI appears in and which fee schedule they're adjudicating you on today. Write the answers down. You can't ask a carrier to fix a rate you didn't know they were using.
What are your top codes actually paying you?
Most owners have a rough sense of this. Carriers don't move on a rough sense.
Pull your top 25 to 35 codes by production and put three columns next to each: your fee, the contracted rate, and the difference. If you're writing off 30% or more on your highest-volume codes, that's where your money goes.
Here's the walkthrough. Say your fee for a D2740 crown is $1,450 and the contracted rate is $905. The write-off is $545, or 38% of your fee. Now say you do 200 crowns a year. That one code is $109,000 in write-offs.
Do that for the whole list and you'll have a single annual number. That's what you bring to a fee review, and it's a very different conversation than "our reimbursements feel low."
Which clauses actually matter?
Four, and they cost more than the fee schedule does.
- Downgrades. Whether the plan can pay a posterior composite at the amalgam rate, and whether that's disclosed. Say your contracted rate on a two-surface posterior composite is $195 and the downgrade pays $145. That's $50 a claim. Twenty of those a month is $12,000 a year, and it never appears as a denial.
- Bundling. Whether the payer can combine procedures and pay one fee for both.
- Timely filing. How many days you have. Ninety-day windows exist, and a claim that ages past one stops being collectible at all.
- Unilateral adjustment. Language that lets the carrier change your fee schedule, or move you to a lower one, without renegotiating. This is the one to read twice.
When can you actually negotiate?
Ask for a fee review 60 to 90 days before your renewal date. That's when you have the most room, because the carrier is deciding whether to keep you.
You're in a stronger position than you think if you've been in-network at least a year with high patient volume, a clean claims history, and low denial rates. Carriers keep providers whose claims pay on the first pass. They can look all of that up, which is what makes it worth saying out loud.
If your denial rate isn't clean, fix that before you ask. Our guide to appealing a dental insurance claim denial covers the mechanics.
How do you know you were paid on the right schedule?
You often don't, and it costs more than the fee schedule does.
With leased networks, a patient with a Cigna PPO card can be paid on an Aetna fee schedule. If your software expects one number and the payment comes back as another, somebody posts an adjustment and the claim closes. That adjustment can hide a real underpayment for months.
The check that catches it is payment as a percent of your billed fee, tracked by payer. Say a payer sat at 62% of your fee for two years and drops to 57%. Nothing was denied and nobody sent a letter, but on $400,000 of billed production through that payer, five points is $20,000 a year. Our post on the reports worth running covers where that fits alongside the rest.
When you're posting these, post the adjustment against the right plan so the year-end numbers mean something.
Autumn compares what each payer paid against what your contract says they owed, on every claim, which is the part nobody has hours for. If you want a read on which of your payers has drifted, we do a free billing consultation. It doesn't take anything on your end.
What is dental network leasing?
Network leasing is when a carrier you've contracted with shares your negotiated fee schedule with other carriers and networks. You end up in-network with payers you never signed an agreement with, and claims can be processed on the lowest schedule available. It's sometimes called a silent PPO.
How do I find out which PPO networks I'm in?
Call each carrier and ask which networks your NPI is listed in and which fee schedule they're currently adjudicating you on. Compare that against the contracts you've actually signed. The gap between the two lists is leased and umbrella network participation.
When should I negotiate my PPO fees?
Sixty to ninety days before your contract renewal date, when the carrier is deciding whether to keep you. Bring the annual dollar value of your write-offs on your top 25 to 35 codes, plus your claim volume and clean claim rate.
Is it better to be in-network or out-of-network?
It depends on your market, not on the math alone. Out of network you bill your own fee and take no contractual write-off, but the patient owes the balance. We covered when that math actually works separately.
