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Thinking of becoming a fee-for-service dental practice? Start by developing “FFS habits”

Sept. 29, 2023
If you think dropping out of insurance networks is impossible, you haven't approached it the correct way. Here's how to join the thousands of dentists who've achieved this freedom.

Have you ever thought about practicing dentistry without an insurance company looking over your shoulder? As dental insurance companies have pushed doctors to work faster and cheaper, practice owners have sought to reduce their dependence on network participation. Some are dropping out of their restrictive or low-paying plans. Others, including me, have moved completely out of network to a totally fee-for-service (FFS) practice model.

In a FFS practice, your patients, not their insurance companies, are responsible for the cost of their care. Patients pay you at the time of service and any insurance reimbursement is sent directly to them. You can (and should) assist them in getting reimbursed, but the responsibility lies with them. You have the freedom to set your own fees, and the freedom to collect them. Does this sound too good to be true? Remember, your patients also have the freedom to leave you for a dentist who does accept their plan, so it’s important to be careful and deliberate when you take those first steps.

For some dentists, the idea of dropping out of insurance networks may seem like wishful thinking. For others, it might seem like a sure ticket to disaster and bankruptcy. It is neither; it’s just a different way to practice dentistry. Anyone who tells you it’s impossible simply hasn’t done it.

You do need to believe that your care has real value, and that there are people willing to pay for it. FFS practices exist throughout this country, and not just in wealthy areas and big cities. Anywhere you are in the country, there are always some FFS practices.

To be clear, there is nothing wrong with practicing in-network. Some of the best dentists I know participate with many plans and have no desire to change. You can deliver quality care and earn a good income in-network. But it’s become steadily more difficult to do so as insurance companies tighten the screws more every year. But I hate the thought that some dentists stay in-network due to fear or because they don’t know how to get started.

I do NOT recommend immediately dropping all your insurance contracts. This might be the type of advice you see on Facebook or in online chat groups, but very few things in dentistry go well without careful planning.

If you’re interested in exploring whether FFS might be right for you, here’s some advice based on my experience. These are the steps I took 10 years ago when I was preparing to drop my network participation contracts. I began by first acquiring a few “FFS habits” that may not be a part of an in-network dentist’s regular arsenal.

Insurance companies do not reward these habits; the real reward is an improvement in the quality and efficiency of the care you offer. They can also improve patients’ perception of value and your relationship with patients.

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Diagnose and treatment plan the whole patient, not just their insurance

If you know an edentulous patient’s insurance company will only pay for a denture, do you still present the options of implants and an overdenture, or a full-arch fixed prosthesis? If an adult patient has a malocclusion, do you offer them orthodontics? Do you offer fluoride varnish to all high caries adults, even knowing it will never be reimbursed? If you don’t, how would your patients even know these things are available?

When I see a new patient now, I don’t know what insurance plan they have. I don’t even need to know if they have insurance at all. This isn’t relevant information in my treatment room now that I’m out-of-network. We all know that insurance companies place many arbitrary limitations on what they’ll reimburse. They have procedure exclusions, annual maximums, frequency limitations, deductibles, and more. None of this has anything to do with a patient’s health; it’s just about saving money.

Unfortunately, many doctors have been conditioned to treatment plan around these restrictions instead of planning what would benefit the patient. I once suffered from this malady. When I was in-network, I was tempted to treatment plan this way because I didn’t have to explain to patients the many options their insurance company wouldn’t cover. But now, when a colleague tells me “my patients won’t do anything that isn’t covered,” I can’t help but wonder how they know if they don’t ask.

When I was in-network, I fooled myself into thinking I was doing patients a favor by trying to save them money. But what I was really doing was avoiding my professional responsibility to present them with all their options. I was also denying them the opportunity to say “yes” to what they really needed, even if they had to pay for it themselves. I stopped treatment planning like this way before I exited the networks, and it resulted in better clinical results for my patients and more production for me.

Slow down (when you can)

There is something I call the “culture of quickness” that can develop in high-volume insurance practices where everyone is pressed for time, and where low fees must be made up in higher volume. You see people moving quickly, talking quickly, and doing multiple tasks simultaneously. Nobody sits down to have a conversation.

This might make you feel busy or in demand, but it can make patients feel nervous and undervalued. Nobody wants to be treated by a doctor who’s in a hurry. Your patients don’t want to feel like a speed bump that’s slowing you down from more “important” tasks in the office, especially if you expect them to pull out their wallet at the end of the appointment and pay you.

You can alter this habit by moving swiftly between patients, but slowing down when you’re with patients. When you slow down, sit down, speak slowly, and look your patients in the eye, you communicate better. You can find out the other things they may want or need. If you want to succeed out-of-network, finding out what’s going on in a patient’s mind is just as important as finding out what’s going on in their mouth.

One of the reasons insurance companies reimburse so little for clinical exams is to encourage you to spend very little time on them. Do you think the companies want you to do truly comprehensive exams? They sure don’t want to pay to treat the additional pathology you’ll uncover. If you don’t give yourself enough time to diagnose properly, you can’t explore anything more than the most basic treatment needs.

Two of the major benefits I received from going out-of-network were not money, but time and freedom. I no longer need to squeeze every productive second out of the day. I can take more time to talk to patients, which helps me diagnose better and treatment plan more effectively.

Learn good clinical photography

Start taking more and better photographs. Improve your photography skills with your intraoral camera and clinical camera system. Take before-and-after shots, even of minor procedures. If you don’t have a good clinical camera with a flash and macro lens, it’s a worthwhile investment. There are some great CE courses that can help you learn how to use the camera equipment. A picture may be worth a thousand words, but it’s more than that. There are things your patient should know that are literally impossible to communicate verbally. The efficiency boost you gain from good clinical photography is undeniable.

Excellent photography also has tremendous value in patient care and marketing. It takes a little extra time to do it properly, so it often gets overlooked. Photos are a critical tool toward self-improvement because you’ll see things you might have missed. But photographs also communicate value to patients.

Beautiful, valuable things get photographed. We know this from the abundance of photos we see of sports cars, supermodels, and exotic destinations. When you photograph your work, you’re communicating that your work is beautiful and valuable. This sense of value is what will keep patients coming back after you no longer accept their insurance.

Acquiring FFS habits doesn’t just prepare patients for you to move out of network, it also gets you ready to move out of network. Many of us don’t fully appreciate the limitations that insurance companies place on our thinking. I didn’t realize it when I was in network; it was a slow awakening. If you want to practice free from insurance interference, don’t take as long as I did to learn these habits!

About the Author

Mitchell Rubinstein, DMD

Mitchell Rubinstein, DMD, has been practicing dentistry in New York City for more than 30 years. He is a Fellow of the American College of Dentists and serves on the research faculty of the University of Rochester's Eastman Dental Institute. He has advanced training in anesthesia/pain management, implantology, oral medicine, and geriatric dentistry. He is engaged in clinical research with the National Dental Practice Based Research Network, a NIH funded network focused on improving outcomes in dental and oral health care.