Ep. 253: Breaking Up with Insurance: A Step-by-Step Guide to Getting Out of Network — Part 3
You’ve planned your PPO exit. Now it’s time to put that plan into action. In the final installment of this three-part series, Jeff covers steps seven through nine, including how to train your team, communicate the change to patients, and confidently drop your remaining PPO plans.
Handouts - https://www.mgeonline.com/ep-253-podcast-downloads-form-page/
Free Fees & Plans Analysis - https://www.mgeonline.com/fees-and-plans
The Get Out of Network Blueprint Seminar - https://www.mgeonline.com/out-of-network-blueprint
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Questions From This Episode
What are steps seven, eight, and nine in the get-out-of-network process?
Step seven is briefing, training, and drilling the entire team before any plan is actually dropped, so everyone can confidently handle patient questions. Step eight is dropping the first plan or plans from bucket one and monitoring closely. Step nine is working through the remaining buckets, the larger plans in bucket two, then Delta in bucket three, until the practice is fully fee-for-service.
How should staff be trained to handle a patient who calls saying they got a letter claiming the practice is out of network?
Acknowledge the letter directly, explain that it doesn't change their care, and confirm whether their specific plan includes out-of-network benefits. If it does, staff can explain that preventive and diagnostic visits remain fully covered, claims are still filed on the patient's behalf, and any future treatment involving a copay will be fully explained before it's scheduled, so the patient understands they can still be seen there.
What are the three options when a plan won't allow the practice to accept assignment after dropping it?
Ask the patient to pay directly, which can create some friction. Wait for the insurance company to pay the patient and let them pay the practice once that happens, which carries some risk but has worked out fine for clients willing to accept it. Or have the patient sign a formal agreement stating they'll pay if the insurance company hasn't paid by a set date, with an attorney reviewing that agreement before it's used.
Why does Jeff recommend not sending a letter to patients unless the insurance company sends one first?
Because reaching out unprompted, when the patient hasn't heard anything and may not have noticed any change at all, can create confusion that didn't previously exist. If an insurer like Delta sends a letter first, worded in a way that can make patients think they can no longer be seen, that's the moment to respond directly with a clarifying letter and a follow-up call, not before.
Should a practice consider renegotiating its fee with a plan instead of dropping it entirely?
It can make sense as a temporary step for one specific plan while dropping the others, especially if the renegotiated rate lands within 5 to 10 percent of the practice's private fee. The real risk is that a renegotiated rate isn't guaranteed to keep pace with inflation the way an independently set private fee would, and pursuing renegotiation broadly can also result in being pulled into a larger umbrella network with additional plans never explicitly agreed to.
Episode Transcript
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This is the final episode of the Breaking Up With Insurance series, part three of three, covering how to get out-of-network and build a fee-for-service, profitable practice. If you've been with me the last two weeks, you already know where we are. If you're just joining now and haven't heard parts one and two yet, welcome, but you may want to go back and start there first.
This is a nine-step process for getting out of plans, and episodes one and two covered the first six steps. This series builds on itself, so jumping in at step seven, which is where we're starting this week, is a bit like walking into the third act of a movie and wondering why everyone's yelling at each other. I've linked both prior episodes on this episode's webpage if you want to go back.
Quick recap of where we've been. In part one, we covered the first three steps: maximizing your new patient flow, aggressively reactivating your existing patient base, and doing your plan homework, building a plan information sheet with patient counts by plan, negotiated fees, out-of-network UCR benefits by plan, and your contract notice periods. If you remember nothing else from that episode, remember that roughly 70 percent of a general practice's income should come from patients of record.
In part two last week, we got into the actual mechanics of the exit: how to sequence which plans you drop, in what order and why, and how to handle your fees throughout the transition. Which brings us to today, steps seven, eight, and nine.
I'll tell you up front, this is the part where practices that don't pull this off actually fail. It's almost never the analysis, and it's not the sequencing. It's the execution, the human side of it. So this week we'll cover how to communicate the change to your patients so they hear it from you the right way, not at checkout or, worse, after treatment's already done. How to train and drill your staff so they're not winging it when a patient asks why you're no longer on their plan. And then we'll get into actually dropping your first plan through your last one, until you're fully fee-for-service.
I should mention, we have staff scripts for various patient scenarios, a new patient asking if you're in their network, an existing patient with questions, and so on. We'll go over those, along with letters you can send if a plan you drop decides to reach out to your patients directly. As I mentioned last week, the way some of these letters are worded tends to make patients think they can no longer come to your practice at all, which isn't true.
I want to reiterate three things before we get into it. Whether you're 20 percent in-network or 80 percent in-network, the steps are the same, it just takes longer at 80 percent. This is designed for you to move at whatever speed is comfortable for you, you have to be able to sleep at night. And this process can genuinely feel confusing and even a bit scary, which is completely understandable. If you want direct help along the way, we offer a free Fees and Plans Analysis with one of our practice management specialists, or you can join our Get Out of Network Blueprint seminar, a two day virtual event we run monthly for around 500 dollars with a money-back guarantee. Both are linked on the episode webpage.
Standard disclaimer before we get rolling: this information is for educational purposes only. It is not legal, tax, accounting, insurance, or professional advice, nor a substitute for it. Decisions regarding insurance participation, PPO contract termination, fee setting, marketing, or any other business or clinical action involve real legal and financial risk. If you apply anything covered here, you are solely responsible for reviewing your own contracts, state regulations, fee schedules, and legal obligations, and you should consult licensed legal counsel, state regulatory authorities, qualified tax professionals, insurance advisors, or other appropriate professionals before making any changes to insurance participation or fees. I'm providing this information, and if you use it, you're responsible for how you use it, though I do recommend getting proper professional advice first.
So, quick recap of the first six steps: maximize new patients, aggressive patient reactivation, do your homework, assign plans to three buckets, sequence how you'll drop them, and adjust your fees. We haven't actually rolled out that fee adjustment yet, we've just calculated it. So what are steps seven, eight, and nine?
Step seven, and I'll probably spend the most time on this one, is briefing, training, and drilling your team. You do this before dropping any plans, because step eight is dropping your first plan or plans, and step nine is working through the rest.
Let's talk about training your team. Up to now, your office manager has probably been working through this process alongside you. Now it's time to get the entire team on board. Hold a staff meeting with everyone present and explain exactly what you're doing. It's important the team understands this is being done to benefit patients, the practice, and them, the team, all together.
Explain why you're going out-of-network, and explain out-of-network benefits clearly. The negotiated fee is what you've agreed to within a given plan, separate from your private fee, and many PPOs also offer out-of-network benefits. The first reaction when you bring this up with your team is often, everyone's going to leave. So explain clearly that out-of-network benefits genuinely exist, and walk through your specific strategy. You may need to revisit some of the definitions covered in episode one.
Explain how you'll gradually drop plans, and how strengthening new patients, hygiene, customer service, and treatment acceptance is a critical part of this whole transition. Then explain how the team will get trained and drilled on handling patient questions, since that's usually where people get flustered, what am I supposed to say? You're the one presenting this plan, but they're the ones fielding the actual calls.
I don't think you'll get much pushback on the basic theory of going out-of-network, the real question is always, what do I say when a patient calls upset or confused? You tell them you have real information and training for exactly that, and you're going to make sure they're 100 percent comfortable handling it.
I can't overstate how important this training and drilling step is. Done poorly, it can create a genuine mess. Your team has to be able to confidently handle questions from both new patients and existing patients once you go out-of-network. We have sample scripts and letters for this, we made them, they're samples, adapt them however makes sense for your practice and your comfort level. Review them with your team and make adjustments together so everyone's genuinely comfortable using them.
Let's go through a few of these. First, questions from existing patients. Two scenarios here: explaining in-network versus out-of-network benefits directly, and handling a patient who received a letter from their insurance company after you've dropped a plan.
As an aside, when would you actually send a letter out proactively when dropping a plan? I've been asked this often, and here's my take, not a hard rule, just my recommendation. I wouldn't send anything out unless the insurance company sends something first. If a patient hasn't heard anything and I proactively send them a letter about a plan change, that can actually create more confusion than a live conversation would.
Whereas if Delta, Cigna, MetLife, Aetna, or another carrier sends a letter, and Delta usually does, they tend to be the most frequent offender here, they often write these in a way that leaves the patient with the impression you can no longer see them. Legally, the letters don't quite say that, they're worded just vaguely enough to avoid that, but the practical effect is the same. If that happens, we have response letters you can send. And again, get any of these scripts or letters reviewed by your own attorney before using them, especially anything in writing.
Here's sample language for explaining in-network versus out-of-network benefits. A patient asks what it all means. You might say: insurance can definitely seem confusing, so here's an easy way to break it down. Your plan is a PPO, and PPO plans typically include two types of benefits, in-network and out-of-network. Your plan allows for both.
Make sure that's actually true for the specific plan before saying it, some PPOs don't offer out-of-network benefits at all, which functions almost like an HMO at that point, though most PPOs do include it. Continue: your yearly maximum is exactly the same either way, nothing changes there. Your cleanings, exams, and X-rays won't have any out-of-pocket cost compared to before, those remain fully covered just as they've always been.
This is exactly why we talked about lowering your preventive and diagnostic fees to match the out-of-network UCR for your largest plans. Say two big plans make up 60 percent of your practice, and the out-of-network benefit for a standard adult cleaning code is 96 dollars for one and 92 dollars for the other. You'd likely set your private fee at 92, covering both fully. You might worry that lowers your hygiene revenue, but it doesn't, if 80 percent of your practice is currently in-network getting a negotiated fee of, say, 46 to 52 dollars, you're actually increasing revenue on that 80 percent while only slightly lowering the fee for your smaller private patient segment.
It also makes hygiene stickier from a marketing standpoint, retention improves because a cleaning genuinely costs less for the patient than before. And the more hygiene patients coming through the practice, the more opportunity there is to help people overall. If only 20 percent of your practice is currently in-network, this specific strategy may not make sense, you might just drop that 20 percent outright instead. But at 70 or 80 percent in-network, this approach helps you exit while genuinely retaining patients.
Continue the script: if the doctor ever recommends something involving a copay, we'll always fully verify your benefits and go over everything with you before treatment starts, so you'll know exactly what's covered and what to expect. The most important thing to know is your preventive care, cleanings, exams, X-rays, is still fully covered, your yearly maximum is unchanged, and your plan works both in and out-of-network, so yes, you can absolutely continue your care here just like before. This script is downloadable on the episode webpage.
Now, say a patient actually calls after receiving a letter from their insurance company. Response from whoever answers the phone: of course, I'm really glad you reached out. These letters can be confusing, and you're definitely not the only one who's received one. Let me explain what it means, because your care isn't changing.
Your receptionist verifies the plan and confirms it includes out-of-network benefits, if it doesn't, that conversation needs to go differently. Continuing, assuming it does: recently, we reviewed our contract with, insurance company name, and decided it wasn't the right fit for our practice anymore. Staying in-network would have required changes that didn't align with how we prefer to care for patients, so we chose to stay independent, but you can still come here just like always.
The patient may ask what that actually means for them. Response: the good news is your plan is a PPO, which means you have both in-network and out-of-network coverage. Your cleanings, exams, and X-rays are still fully covered just like before, and we still submit all your claims. Nothing changes on your end. If they ask about needing treatment: as always, if the doctor recommends anything involving a copay, we fully verify your benefits first and go over everything before treatment starts, so you'll always know exactly what to expect.
If they ask, so I can still come here? Of course you can. Nothing changes about your care here, you can keep coming just the same, and we'll walk you through anything you need. Would you like to schedule your next visit? The whole point is making sure the patient understands they're still welcome, since the impression a lot of people get from these letters is that they can no longer be seen at all.
Now for new patients calling in. Do you take my insurance, or are you in my network? Sample response: of course, what insurance do you have? Great, and what were you hoping to schedule today? Say it's a cleaning. This doesn't replace your actual intake form, get their name and number in case you're disconnected, but here's the concept.
Say you've done your homework and know this specific plan pays out-of-network benefits that match your adjusted fee schedule, meaning they'll cover the cleaning at 100 percent. You can say: yes, insurance XYZ will cover 100 percent of your cleaning here, so let's get that scheduled. Just bring your insurance information so we can fully verify everything, that way if you ever need anything else, we can go over exactly what's covered. But for now, yes, your cleaning is covered 100 percent. What day works best for you?
Notice you're not telling them you're an in-network provider, you're not, but you've done the homework to know their specific out-of-network benefit lines up with your fee. There will always be some financial conversation for basic or major treatment either way, in-network or out, since your fees for those categories are now set at the 50th to 70th percentile for your area. So the patient ends up paying somewhat more there and somewhat less on hygiene than they would have under the old negotiated fee.
For an emergency patient calling in pain: of course, what insurance do you have? Great, thank you, we accept that plan, the exam and any X-rays the doctor needs will be covered at 100 percent, since your preventive and diagnostic fees are set within that plan's UCR. If they ask about treatment: before we do any treatment, we'll fully verify your benefits and the doctor will discuss exactly what's recommended, and we'll work out the finances together, so there's never a surprise bill.
Take these scripts, review them with your team, adapt them to your own practice so everyone's genuinely comfortable, then drill them until staff can handle questions naturally rather than having to think it through in the moment. Notice the difference between handling this well versus simply saying, no, we don't take that, sorry, when a patient calls. That second version, they're just going to leave. Whereas if your fees are genuinely set at UCR for preventive and diagnostic, you can honestly tell them yes, that's fully covered here, we're not in-network technically, but we'll file your claim and you'll be covered at 100 percent. We're not misleading anyone, but we're also not shutting the door in their face.
Here's a trickier scenario: a plan where you know, from your homework, that in-network pays something like 100, 80, and 50 percent for preventive, basic, and major, but out-of-network pays only 90, 70, and 40. Sample script: let me check for you, what insurance do you have? Great, and what were you hoping to come in for? A cleaning. With this plan, your cleaning is covered at 90 percent, meaning there's a small 10 percent copay, in your case around 15 to 20 dollars. Would that work for you? Most patients say yes without hesitation. Occasionally someone won't want to pay anything and may not schedule, but that's a small minority. I'd always disclose this upfront rather than surprise anyone later.
Get your whole team together, carve out real time, review every script, adapt them to your practice, and then drill, drill, drill, pairing staff up to run through scenarios with each other, starting easy and working up to the hardest questions they might realistically get. Whoever answers the phone should practice taking these calls until it feels completely natural. This is exactly where things typically go wrong: you drop your first plan, staff aren't genuinely prepared, an upset patient call happens, and people start generalizing that everyone's upset, the schedule's suddenly emptying, and it spirals. If everyone is thoroughly prepared first, even if it adds an extra month before you drop anything, it's completely worth it.
It's worth including hygienists and assistants in this training too, even if they don't answer phones, since patients will ask them directly why the practice went out-of-network. One honest note here, just between us: if you were only getting half of what a procedure is actually worth under a PPO, your lab isn't giving you a discount because the patient has that plan, your landlord isn't either, your assistant isn't taking less pay, and your equipment doesn't cost less. The only person absorbing that gap is you, and eventually that catches up with you financially.
That said, I wouldn't use that framing directly with patients, the insurance company was paying me too little, since very few people will have real sympathy for that framing, even if it's true. I'd also avoid saying anything like, staying in that plan meant I couldn't deliver high quality care, since there's nothing in most of these contracts that actually mandates lower quality, and that kind of statement could genuinely create problems with the insurer down the line. Keep the messaging simple: it just wasn't the right fit anymore, we decided not to continue in that network. Leave it general, especially in writing, and have your attorney review anything you send out.
That covers step seven. Now step eight, dropping your first plan. Before you actually pull the trigger, here's where you want to be: marketing and reactivation cranked up, your homework done, your new fee schedule live, preventive and diagnostic lowered to match your biggest plan's UCR, basic and major raised to the 50th to 70th percentile for your zip code, and your team fully briefed, trained, and drilled.
A couple of things worth having ready. First, a letter template in case the insurance company reaches out to your patients directly, Delta has a real chance of doing this, others less often, though it's become more common. I have a sample Delta-specific letter, and I'd definitely have your attorney review anything like this before sending. Here's the gist: dear patient name, we're writing to follow up on a letter you may have received from Delta Dental regarding your participation status. These letters can sometimes be confusing, so we wanted to explain what this means for your care in our practice.
After a recent review, we made the decision not to renew our contract with Delta Dental for certain plans. As a result, our office is now considered an out-of-network provider for these plans. We want to reassure you that you can still continue receiving care in our practice, and we're still here to help you use your available benefits. Most Delta PPO plans include out-of-network coverage, and many patients experience little to no change in how preventive services are handled. As always, we'll continue to see you as a patient, verify your benefits, file your claims, and review any copayments or coverage details with you before treatment is scheduled. If you'd like us to look into the specifics for your plan, we're happy to help, please call us. Thank you for your trust, we look forward to continuing your care.
I'd follow a letter like this up with an actual phone call where possible. And to be clear, I'm not trying to slam Delta on the way out, even though when I bring them up in front of a room of dentists, it tends to land like a dead fish, people get genuinely sour about it, not at me, just at the situation. I understand it, but the messaging still needs to stay measured and professional.
I want to be clear too, I've had a lot of clients navigate these nine steps successfully. Don't panic. Some have lost as little as 10 percent of affected patients, occasionally up to 30 percent, and it hasn't been a serious problem either way. I also have a general sample letter for notifying patients that you're out-of-network with a given carrier, both letters are available as downloads.
Once you're ready to drop your first plan: change your private fees live as covered in step six, make sure staff are fully familiar with the new numbers, then start with bucket one, the easiest plans to exit. If you have, say, five thousand patients spread across six small plans with only 25 patients each, you might be comfortable dropping all six at once. Make sure staff know exactly which plans are being dropped, whether those plans offer out-of-network benefits, and how to answer likely questions.
If a plan won't allow you to accept assignment once you're out-of-network, and that does happen, sometimes a plan tells you one thing and then keeps paying you directly anyway, I'd still prepare as if they won't. You have three real options here. One, ask the patient to pay you directly, which can create some friction. Two, wait for the insurance company to pay the patient, and have the patient pay you once they receive that payment, this carries real risk of nonpayment, but I've had a client do exactly this when dropping Delta, and it worked out fine, he still collected more overall than he had in-network. Three, have the patient sign a formal agreement stating they'll pay you directly if the insurance company hasn't paid within a set window, we have a sample called the Non-Assignment of Benefits Acknowledgment and Patient Payment Agreement, and this absolutely needs attorney review before use, especially if it involves storing a card on file, which carries its own compliance requirements.
Since bucket one is your easiest set of plans, treat it as your test run to work out any real kinks. After dropping your first plan or plans, monitor closely, meet regularly with your team, don't let up on new patient marketing or reactivation, and make adjustments as needed. If things are going well, move on to the next plans in bucket one, letting each round settle before moving to the next, and keep your team looped in throughout, including which bucket you're currently working through.
That's step eight. Step nine is simply continuing through the remaining plans, not all at once, since bucket two and Delta specifically get more complex. Bucket two holds your larger plans, handle these carefully, repeating the same rhythm, drop, monitor, adjust, stay flexible, until bucket two is fully empty.
Then bucket three, Delta. Dropping Delta often requires a bit more care, since they're more likely to reach out directly to your patients in a way that can create confusion about whether they can still be seen. If Delta does send a letter, respond with your own, reviewed by your attorney, and go over that response together as a team before sending, so everyone's using the same unified messaging if a patient calls about it.
Also review your Delta contract thoroughly beforehand, for instance, if you're a Delta Premier provider, you may be able to retain Premier status while dropping Delta PPO specifically. There's generally no new enrollment into Premier, you'd need to already be grandfathered in, but this and any other Delta-specific nuances should be fully explored before you drop your first Delta plan.
Once Delta is fully dropped, you are completely plan-free. Well done, genuinely, that's a real milestone worth celebrating with your team.
Before wrapping up, let me run through some of the most common questions we get on this. Do you need to stay credentialed once you're out-of-network? No, credentialing is specifically for in-network participation.
Should you start a membership plan? I'm a fan, as long as you set it up correctly for your practice. The real challenge isn't the plan design itself, it's adoption. Make sure you're actually positioned to administer it well, that it works for you financially as recurring revenue, and that you can genuinely sell it to patients, otherwise you end up with a plan and a tiny handful of members that's more hassle than it's worth.
How quickly should you get out-of-network? At whatever pace lets you sleep at night, that's the whole reason we start with the easy bucket first, so you can see it's more manageable than it feels going in.
Should revenue go up or down as you're dropping plans? It should start climbing fairly quickly. I have seen practices dip briefly before rebounding, I don't love seeing that, done correctly, revenue should hold steady at minimum, and generally increase as you go.
What if I renegotiate my fee and it lands close to my private fee? This is genuinely situational, and depends heavily on how many other providers in your area take that same plan. If they don't have many providers, you have real leverage. You might renegotiate one specific plan down to 5 to 10 percent below your private fee while dropping the other four in that same bucket, but there's no guarantee that renegotiated rate keeps pace with inflation the way your own private fee would over time. If you go this route, reserve the right to drop that plan eventually anyway, and watch out for umbrella networks, where renegotiating can quietly pull in additional plans you never explicitly agreed to.
Last common question: I'm already overbooked, why would I market or reactivate more right now? I'd still recommend doing some regardless. If you're severely overbooked, the real fix is usually more capacity, not necessarily more chairs, but possibly more assistants or an associate, genuinely depends on your specific situation, feel free to email me directly if you want a second opinion on yours. In many cases, you'll lose some patients through this transition, so reactivation helps refill that capacity with patients who fit where you're headed.
So here's where this all ends up. You move through these nine steps at your own pace, and one day you look up and you're done, for all practical purposes a fully fee-for-service practice. You control one of the most important levers in your own business, your fees, no longer tied to insurance company rules, discounts, or restrictions. When your costs rise, you adjust, the same as any other business gets to. And most importantly, you get to focus fully on quality care, clinical freedom, and serving patients exactly the way you know is right, nobody in the room with you except you and the patient.
I said at the start of this series that I've yet to meet a doctor who genuinely loves being in-network and collecting fifty cents on the dollar, not one. What keeps most people in is fear, the fear of an empty chair feels very real. But having heard the entire process now, I hope this doesn't feel like a leap off a cliff, it's nine concrete steps you can take one at a time if needed, and the only step that actually costs you anything by delaying is the first one.
Remember the backdrop here: costs aren't going back down, reimbursements aren't suddenly going up, no insurance company is waking up tomorrow deciding they've underpaid dentists. Every year you wait, the math gets worse, not better. The doctors who handle this now are the ones positioned to take full advantage of everything covered in the State of the Industry episode, episode 248, which I'd recommend listening to alongside this series, since economically, this may be one of the biggest opportunities dentistry has seen in a long time.
If you want help, the two options remain the Fees and Plans Analysis and the Get Out of Network Blueprint seminar, both linked on the episode page. I've also put every download from all three parts of this series there, the plan information sheet, sample scripts and letters, the Reactivation Program, the Care Enough to Share program, and a link to the MGE New Patient Workshop.
One last thing. Once you're on the other side of this, someone's going to ask what's next, and that's entirely up to you. You'll have conquered something a lot of your colleagues are still struggling with, I was giving a seminar just today for new clients and asked for a show of hands on who's still fully in-network, 70 to 80 percent of the room. My honest suggestion once you're through this: pay it forward, show your colleagues it can genuinely be done, and help restore the most important relationship in dentistry, the direct one between doctor and patient, without an insurance company in the middle. That's how private dentistry survives, one practice at a time.
If you have questions about anything covered in this series, email me directly at jeffb@mgeonline.com. All the downloads are on the episode webpage, and if you want to learn more about MGE, visit us online at mgeonline.com or call 800-640-1140. Thanks for sticking with me through all three parts of this series. Have a great week, and go take that first step. We'll see you at the next episode.