Ep. 259: Is There a Million Dollars Sitting in Your Software?
Your incomplete treatment list may represent one of the biggest untapped opportunities in your practice. In this episode, Jeff explains how to reactivate these patients, bring them back into the office, and get more diagnosed treatment accepted.
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Questions From This Episode
According to Sabri's data on new MGE clients, what percentage are typically still in-network, and how many of the ones who've tried dropping plans end up going back?
Roughly 85 percent of new clients are still in-network, a conservative estimate, with another 10 to 15 percent out or in the process of getting out. Of the practices still in-network, about 10 percent have actually tried dropping a plan at some point and taken it back, and about half of practices currently out of network are having real financial problems as a result.
What are the four foundational pieces that determine whether dropping insurance plans actually works?
Control over new patient flow through effective marketing, a genuinely functioning hygiene department that pulls existing patients with outstanding treatment back onto the schedule, healthy treatment acceptance so the practice can actually sell the dentistry it diagnoses, and staff trained specifically on how to talk to patients, new and existing, about being out of network. Practices that struggle after dropping plans almost always have one or more of these four already weak beforehand, since being in-network had quietly been propping up the business.
Why does the hygiene copay cause so many patients to leave once a practice drops a plan, and what's the actual fix?
Patients are used to preventive care being fully covered, and even a small new copay, sometimes as little as $15, creates the sense that something changed and they're now being charged for something insurance used to pay for, which people respond to badly regardless of the dollar amount. The fix is finding the UCR, or usual, customary, and reasonable, fee for preventive and diagnostic codes, which sits between the old negotiated fee and the full private fee, and setting that as the new fee for those codes specifically, so out-of-network patients still get 100 percent coverage on cleanings and exams.
How can a practice actually find out what a given insurance plan's UCR fee is for a specific code?
Call the insurance company and play what Sabri calls the over-under game, asking whether the fee is higher or lower than a given number until you narrow in on the actual figure, since insurers won't simply state it outright. Open Dental users have an easier option through a crowdsourced feature called the Blue Book, and once real claims start coming back, the UCR shows up directly on the EOB, so a spreadsheet can be built up within about a month even without knowing every fee in advance.
Why did Sabri end up building her own insurance billing company, Smile Care Claims, instead of just recommending outside vendors?
Outsourcing insurance filing frees up a trained staff member to focus on things that actually drive revenue, like reactivating patients or supporting treatment presentation, but Sabri kept running into outsourced vendors where nobody was genuinely taking ownership of the account, leading to unhandled accounts receivable and dropping collections. Smile Care Claims assigns each practice a dedicated account manager who learns that specific office and its software, so real responsibility for the work stays in place the way it would with an in-house employee.
Episode Transcript
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Jeff: I've done a lot of episodes on getting out of network and dropping PPOs, and the reason for that is fairly obvious. A lot of doctors want out. If you look at the ADA Health Policy Institute's surveys, more doctors every year say they want to drop plans or are at least planning to. And the reason isn't hard to see either. Over the last five or six years, costs have risen dramatically with inflation, while insurance companies have largely kept their fee schedules flat or actually reduced reimbursement. Basic math tells you why people want out.
Jeff: So if that many people want out, why aren't more of them actually doing it? Also not hard to guess. They're afraid of the consequences, that they'll drop plans, lose a wave of patients, and put the whole practice at risk. So for this week's episode, rather than my usual here's how you do it and here's why it's positive, I wanted to look at the actual downside for a moment. Especially with newer clients, have we seen people drop plans and have it genuinely go wrong? Yes, we have. But we can also identify exactly what caused it to go wrong. So that's what we're covering this week, the specific failure points that can cause a plan exit to not work out. Joining me is Sabri Blumberg, our Deputy Chief Operating Officer here at MGE, who also oversees all of our technical delivery.
Sabri: Happy to be here.
Jeff: Let's start with some numbers, since you work directly with a lot of our new clients. Of all our new clients, private practice owners, what percentage are currently in network?
Sabri: I'd say 85 percent, and that's a conservative estimate.
Jeff: So at least 8 out of 10, maybe 9 out of 10. And the remainder, either fully out or down to just a few small plans, that's roughly 10 to 15 percent. Of that group, how many are actually having financial or practice problems as a result of dropping plans?
Sabri: I'd say about half.
Jeff: And of the 85 to 90 percent still in network, how many tried dropping plans at some point and ended up going back?
Sabri: I'd say around 10 percent, either fully reversed or seriously considering it.
Jeff: That's actually consistent with something I've seen in ADA surveys generally, doctors get asked if they plan on making some change, buying new equipment, dropping a plan, and the percentage who say yes is always considerably higher than the percentage who actually follow through. With equipment, people usually end up doing a bit more than they said. With dropping insurance, it's the opposite, people say a large percentage plan to do it, and the number who actually do it ends up much smaller. People clearly have legitimate concerns, since you're fundamentally changing your business model.
Jeff: So say a new client comes to you already out of network and having problems. What did they actually do wrong, or what could they have done differently?
Sabri: It always comes back to four reasons, and they're very predictable. All four are really symptoms of a weak business foundation. To build a genuinely successful private practice, your basics have to be strong. If they aren't, that weakness gets exposed the moment you make a change like dropping a plan, because up until then, it had been quietly propped up by being in network. Everything looked normal, you might not have been making the money you wanted personally, but the business itself wasn't in real danger. The moment you drop that insurance prop, you have to actually run it like a business, and if the foundation isn't strong, that's when real problems show up.
Jeff: So what are the four points?
Sabri: They're simple, genuinely no mystery to them. First, you need good marketing, meaning real control over your new patient flow, both internal and external. Second, you need a genuinely functioning hygiene department, not a revolving door where you're bringing in new patients but never actually getting them into hygiene and generating the dental sales that come from it. Third, your sales need to be strong, meaning healthy treatment acceptance. Your schedule has to actually allow the doctor time to talk to patients, get them on board, and get them to pay for the treatment they need. And fourth, your staff has to be properly trained on how to talk to patients about being out of network, so you're not shutting the door on new patients through poor conversion, or fumbling questions from existing patients. If those four things are genuinely in place, dropping plans usually goes fine.
Jeff: Let's walk through how this actually plays out. Starting with marketing and new patient control, you mentioned one practice that dropped plans with only 60 total patients.
Sabri: Right, that one was almost a non-issue, that was basically the entire practice.
Jeff: But say I'm an established office. When has marketing actually been the problem in the failures you've seen?
Sabri: Either they weren't marketing at all, or, and this was actually the bigger issue, they were marketing, the phone was ringing, new patients were reaching out, but the front desk wasn't trained on how to actually bring in a patient who's out of network. It turns into an impromptu insurance benefits seminar instead of simply getting the patient in the door and making sure there's no real problem.
Jeff: So even a practice spending modestly on marketing and increasing that budget after dropping a plan is still going to run into callers who have some form of insurance and ask about it.
Sabri: A hundred percent. Do you take my insurance is usually one of the very first questions asked. So the front desk absolutely needs to be able to handle that. And this often overlaps with an existing new patient conversion problem, if conversion was already weak while a practice was in network, dropping plans and increasing marketing spend doesn't fix that underlying issue, it just becomes more visible.
Jeff: Walk me through what you actually found when you listened to these calls.
Sabri: In some of these cases, a patient would call and ask, do you take my plan, and the answer was simply, no, we don't, thank you, and the call would end right there.
Jeff: So the patient just calls the next office.
Sabri: Exactly. And there's nothing wrong with the person answering the phone, they simply haven't been trained on how to actually handle that question. This is exactly why, when we're working with new clients, we sometimes have to listen to their actual phone calls to figure out what's happening, since we usually have a pretty good suspicion going in.
Jeff: So say I call as a prospective patient and ask if you take my insurance, after you've dropped that plan. How would you actually answer that?
Sabri: First, you can never lie to or mislead a patient, that creates real problems down the line, so the answer always has to be honest. But there's a bigger piece to this. The real reason practices lose patients when they go out of network isn't the restorative work, patients already expect to pay something for that. It's the hygiene copay specifically.
Jeff: So walk me through that. Someone calls, gets scheduled, comes in, and then asks why they're suddenly paying $100 for a cleaning.
Sabri: Right, and this happens with existing patients too. Even if it's only $15 extra for a cleaning, people aren't used to that change, and people generally don't respond well to change of any kind, that's just human nature. It isn't really that the $15 or even $50 is unaffordable, in most cases it genuinely isn't. The real issue is the question in their head: why am I suddenly paying for this when I thought my insurance covered it? That confusion is the actual reason practices lose existing patients and struggle with new ones after dropping a plan, not the dentistry itself, since patients are already used to paying for that.
Jeff: You've been developing a specific solution to exactly this problem. When did you start working on it?
Sabri: About three years ago. I started really digging into why patients were leaving when there were usually still real benefits available, and that turned out to be the number one reason by survey. So I put together a plan around it.
Jeff: Walk me through it. When a practice goes out of network, it has its own private fee schedule.
Sabri: Right, and normally the private fee for hygiene procedures carries a bigger relative discount compared to the negotiated in-network fee than basic or major restorative work does.
Jeff: So using round numbers to keep this simple: say my private fee for a cleaning, bitewings, and periodic exam is $230, and the negotiated in-network fee for that same set of codes is $115, roughly a 50 percent discount.
Sabri: Right, and hygiene procedures make up the largest share of instances on any given day sheet by far, families bringing in kids, everyone coming in for regular cleanings, so this specific gap affects a huge volume of visits.
Jeff: So if I'm dropping a plan that makes up a big chunk of my practice, what exactly do you recommend?
Sabri: There are actually three relevant fees here, not two. Most people know about the negotiated fee, what you get paid in network, and the private fee, what the fee should genuinely be if you'd kept pace with inflation. But there's a third fee sitting between those two, called the UCR, usual, customary, and reasonable, sometimes called the allowable or max allowable fee.
Jeff: What does UCR actually stand for again?
Sabri: Usual, customary, and reasonable. It's essentially what the insurance company has decided your private fee should be, a cap on what they'll pay for a given code, regardless of whether you're in network or not.
Jeff: Let's use a concrete example, code D1110, a regular adult cleaning. Say the negotiated in-network fee is $50, the private fee is $150. What would the UCR typically be?
Sabri: Probably around $100, maybe $110 if you're lucky.
Jeff: So if I'm the patient and you're in network, my insurance pays you $50. If I have no insurance at all, I pay you the full $150. But if I have out-of-network benefits and you've dropped my plan, the most they'll pay is that UCR figure, around $100. If you bill $150, they'll only reimburse based on the $100 UCR, which can make it look like the patient's being overcharged, even though they'd still typically cover that portion at 100 percent for a straightforward cleaning.
Sabri: Right, and that holds for most PPOs, including most Delta plans, which generally pay the same 100, 80, 50 percentages for preventive, basic, and major work whether you're in or out of network, just against a different fee base.
Jeff: So take a bigger example, a filling. Say the private fee is $300, the old in-network fee was $100 with an 80 percent payout, a $20 copay for the patient. If the UCR for that same filling is $200, the plan still pays 80 percent, or $160, but now the patient owes $140 instead of $20.
Sabri: Exactly right.
Jeff: So walk me through the actual strategy you built to get around that squeeze.
Sabri: The core problem I was trying to solve for MGE clients was that overhead squeeze. In a lot of the newer client situations I was seeing, my honest advice would sometimes have been, you'd genuinely make more money as an associate somewhere else, which is ridiculous, there should be real upside to owning your own practice, and there is, just not while you're heavily in network. There are things you can do to make being in network work better, but ultimately, getting out is the best long-term solution.
Sabri: So the goal was growing real profit margin, not just making collections look good on paper while profit stays thin. Here's what I actually recommend: move all preventive and diagnostic fees, cleanings, exams, anything typically covered at 100 percent, to that UCR figure. In our example, that $100 UCR instead of the full $150 private fee. Then move everything else, basic and major restorative, endo, crowns, implants, up to the full private fee.
Jeff: So walk me through why that actually works.
Sabri: Because you're not really changing the patient's experience on the restorative side at all, they already expect to have a financial conversation about a crown or a root canal. What you are doing is making sure preventive care, the highest volume category by far, stays fully covered at that UCR level, so out-of-network patients aren't suddenly hit with an unexpected hygiene copay. You'll give up a little revenue on preventive care from your existing private-pay patients, but you gain considerably more from the volume of patients now getting fee-appropriate restorative work, and you eliminate the exact friction point that was driving people away.
Jeff: How does a practice actually find out what a plan's UCR is for a given code, since insurers obviously aren't going to just hand that over?
Sabri: You call and play what I call the over-under game. You ask, is it more than $100? They'll say lower. Is it around $90? Higher. You work your way toward the actual number that way, since they won't just state it directly.
Jeff: That's a little absurd, honestly.
Sabri: It genuinely is, but they're a business protecting their own numbers, I understand the motivation even if I don't love the process. If you're on Open Dental, there's an easier option, a crowdsourced feature called the Blue Book that estimates UCRs directly. And you don't need every fee figured out before you start. Take your best guess to begin with, slightly higher than you think it might be, and worst case you issue a few refund checks. Within about a month, your actual EOBs start coming back with the real UCR listed, and you can build out a full spreadsheet from there.
Jeff: Are insurance companies getting wise to this strategy?
Sabri: They're doing all kinds of things. It used to be that out-of-network benefits paid the same 100, 80, 50 percentages as in-network, just against the UCR instead of the negotiated fee. Now some plans have shifted those percentages down to something like 90, 70, 40 specifically for out-of-network care. And I've seen a couple of plans that offer no out-of-network benefit at all, while still calling themselves a PPO, which is really behaving like an HMO at that point.
Jeff: So to be clear: in network, insurance pays 100, 80, 50 percent of the negotiated fee. Out of network with a plan that still offers real benefits, they'll typically pay something like 90, 70, 40 percent of the UCR instead.
Sabri: Right, though that reduced percentage is still a fairly small share of plans overall. There's no perfect solution here, this approach simply covers the majority of situations we run into, and it's the most workable option available. You will run into some patients with a small hygiene copay under this system, but it tends to be minor, maybe $12, and it just comes down to staff being trained to handle that conversation calmly.
Jeff: You mentioned insurance companies are doing other things too, beyond adjusting percentages.
Sabri: They're doing a lot. Some are actually buying dental practices directly. Many now run AI systems that can deny a claim faster than you can even finish writing the narrative justifying it. They've automated the denial side aggressively.
Jeff: Have they automated the payment side at all? Someone asked me recently whether AI might eventually let claims get paid within a day or two if both the practice and the insurer were running AI agents.
Sabri: Technically possible, but that's not where insurers have focused their investment. Their priority has been making denials more efficient, not payments. Maybe that changes eventually, but that's not what I'm seeing right now.
Jeff: Insurance filing has genuinely become more complex as a result. This is where I'll insert a brief plug, since you actually built a real solution around this. You used to recommend clients outsource insurance filing entirely, since salaries for a genuinely skilled insurance coordinator kept climbing, and the skill required kept increasing right along with it.
Sabri: Right, and the logic was sound, that person's time is much better spent helping bring patients back onto the schedule or supporting treatment presentation, work that actually drives revenue, rather than being fully consumed by insurance filing. It was also often cheaper to outsource, and every dollar matters once you're factoring in the discounts that come with being in network.
Jeff: But when you started recommending clients outsource this, what happened?
Sabri: Not universally, but often enough, real chaos. Unhandled accounts receivable, collections numbers quietly dropping, because nobody at the outsourced vendor was genuinely taking ownership of a given practice's account.
Jeff: So eventually you built your own company to solve that specifically.
Sabri: Right, it's called Smile Care Claims. Each practice gets an assigned account manager who actually knows their staff, their office, and their software, so you're always working with the same person rather than a rotating queue. The core problem I kept running into with other vendors was that nobody was truly responsible for a given account. When you outsource something, you want the control to stay with the practice while someone is still genuinely accountable for that area, and that only works if the vendor itself assigns real ownership.
Jeff: I'll put a link to Smile Care Claims on the episode webpage if anyone wants to look into it further, you can book a consultation directly. So beyond the fee strategy, what else falls under fixing hygiene specifically as part of this foundation?
Sabri: Marketing needs to be genuinely under your own control, meaning effective new patient marketing and real reactivation efforts. In dentistry, you make money by selling dentistry, and you can do that two ways, sell to your existing patients or bring in new ones. On average, 60 percent of a dentist's charts have outstanding treatment sitting in them, and if you're not actively working to get those patients back into hygiene, you're leaving that entire sales opportunity untouched. So part of fixing this foundation is genuinely getting inactive patients with outstanding treatment back onto the schedule, which gives you more to actually sell and helps drive the numbers up.
Jeff: So ultimately, you make money in dentistry by actually doing dentistry and getting people healthy.
Sabri: Exactly, so if a chunk of your patients aren't healthy and aren't coming in, take real responsibility for reaching them, educating them further, and working through the financial side so they understand why the treatment matters and are willing to move forward. That's the hygiene and reactivation piece. Sales is the second piece, which we've already covered. And staff training is the third. Once you've solved the hygiene copay issue specifically, handling new patient calls becomes considerably simpler, since the only real question left is what they're actually coming in for. Ninety percent of the time it's a cleaning, and if you've already moved preventive fees to the UCR level, you can tell them honestly that it'll be covered at 100 percent.
Jeff: Assuming the front desk actually knows that's true for a given plan.
Sabri: Right, so they need a working list of which plans conform to that setup and which don't, or at minimum, a habit of saying, let me check that for you, and quickly pulling it up. Especially for plans with no out-of-network benefit at all, that might mean a quick hold while someone checks the portal. But once your staff genuinely knows which plans conform and which don't, it stops being a barrier to new patients at all, it just becomes routine.
Jeff: One more clarification. Once you're out of network and running fee for service, are you still filing insurance for patients?
Sabri: Completely, that service to the patient never changes.
Jeff: Except with Delta specifically, where the check sometimes goes to the patient instead of the practice.
Sabri: That does happen with some Delta entities, though not universally, since the different Delta companies operate somewhat independently, and in practice, I still see checks going to the practice more often than you'd expect, even when they technically shouldn't. Either way, there are ways to handle it. Collect payment upfront if you're comfortable with that, or, if you trust the patient and are willing to wait for reimbursement, have them sign an agreement, ideally drafted by an attorney, authorizing the practice to charge their card automatically after 30 days if the insurance check hasn't been forwarded. There's a workable solution for essentially every piece of this, it just requires real training and a properly built infrastructure.
Jeff: So to sum up: dropping insurance doesn't fail because a practice got out of network. It fails because an existing, weak foundation, in marketing, hygiene, sales, or staff training, gets exposed once insurance is no longer propping the business up. Fix those four things, and they matter whether you're in network or not.
Sabri: Exactly right.
Jeff: For anyone listening who wants real help with this, we have two options. We run a regular virtual seminar called the Get Out of Network Blueprint, a two day event, $500, with a money back guarantee. We also run an in-person version here at MGE in the Tampa Bay area, normally reserved for existing clients, but we're opening it up to podcast listeners too. The next one is October 1st and 2nd, and it's free to attend if you're a listener, just factor in your own travel.
Sabri: We'll walk through the entire process start to finish and answer whatever's specific to your situation. I've got scripts for staff training, exactly what to say and how to actually drop a given plan, and we hand all of that out.
Jeff: I'll put links to both the virtual event and the in-person one on the episode webpage. Sabri, thank you so much for being here this week.
Sabri: Happy to. And one last thing worth saying, don't lose hope on this. It's not all or nothing, you can absolutely do it gradually, on whatever pace actually feels comfortable. But you have to take that first step, research it, look at how different practices are approaching it, get genuinely educated, and try dropping one small plan to see that the world doesn't end and the practice doesn't go under. Do it on whatever gradient makes sense for you.
Jeff: Well said. Folks, if you'd like to learn more about MGE, you can find us online at mgeonline.com or call us at (800) 640-1140. Have a great week, and we'll see you at the next episode.