The complexities of PPO Fee Negotiations in 2025

Narrator: You are listening to Insurance Untangled podcasts, where we explore the various challenges faced by dental practices due to their reliance on insurance. In this podcast, we dive deep into the issues surrounding dental insurance dependence and offer practical solutions and strategies for reducing your reliance on insurance. Join us as we interview industry experts, share success stories, and provide valuable insights to help you take control of your practice’s financial future.

Ben Tuinei: Welcome to another exciting episode of the Insurance Untangled podcast. My name is Ben, and I’m one of the co-hosts on this podcast. And you know, y’all know that we’ve kind of created this for you, the dental community, in an effort to help you untangle yourselves from the big mess that we deal with on a day-to-day basis. And that’s dental insurance. Today I have my trusted colleague here back with us today, Tessina. She’s gonna be sharing some hello, awesome wisdom with us. How are you, Tessina?

Tessina Bullock: Good. How are you?

Ben Tuinei: Doing wonderful, thank you. It’s always great chatting with you. And today we’re gonna talk about a really fun topic. So, so you probably saw in the title for this episode that we’re gonna talk about the current state of PPO fee negotiations in 2025. And when it comes to negotiations, I mean, in this day and age, you have to negotiate fees, right? If you’re looking at your hygiene department alone, it is extremely stressful to practice dentistry in 2025 as an in-network provider because the rates aren’t even covering your costs to deliver a lot of services, right? So, so fee negotiations, it’s a given thing that every practice needs to do.

So, Tessina, first question I have for you is, when it comes to negotiating PPO fees, what’s the first thing that you should do? Or like, first activity you should do with this whole realm of negotiating with insurance?

Tessina Bullock: Yeah. We refer to this as building your insurance profile, right? So you want to—it’s several tasks, but it all comes down to just building out that profile. It’s reviewing your office fees, getting a list together of those PPO plans that you’re currently contracted with, when you were contracted with them, and when’s the last time you negotiated. You wanna review what you’re looking for—are you looking to join or drop plans? What is your focus here? And then you wanna make sure you’re understanding leasing partners—we also call that umbrella networks—and identifying your top 40 most utilized codes in the office. And then, of course, finding the network recruiters. So that is summing it up there—like building your insurance profile.

Ben Tuinei: Yeah, I love it. I love it. I think in the military they have a thing called the SWOT analysis. SWOT—you know, identifying your strengths, your weaknesses, opportunities, and wait—and threats. Yeah, SWOT: strengths, weaknesses, opportunities, and threats, right? So I think what you described there kind of speaks to that. And in the practice setting, it’s—I mean, I guess it’s the equivalent of doing any kind of prep work, right? If you have a good—good preparation or building a foundation for a house—that’s kind of the concept, right? Is that you just have to get prepared.

Tessina Bullock: Yeah, definitely. You wanna be as knowledgeable as possible as you’re headed into your negotiations so that—what are we—so you’re confident. I don’t know, how can you go into any situation if you’re not knowledgeable and comfortable with where you’re at currently to know where you wanna go, right?

Ben Tuinei: Yep. I mean, what it reminds me of is, you know, when I go out to big cities like New York City or even Las Vegas—smaller city—and when I walk around with my son, ’cause we always wake up super early in the morning, we like walking around the cities when we’re there for vacation and not have to run into a whole lot of people. And from time to time, you run into people that are super drunk from the night before, or they’re tweaked out on a certain kind of drug, and they walk up to you and try to give you a hard time.

And I’m a bigger guy, you know, and I’m not afraid of anybody—even if they could get the best of me, I don’t give an ounce to people in terms of fear when I’m out in public, especially with my son.

Ben Tuinei: And a lot of times when we get approached by people that are drunk—I mean, I’m not gonna hurt them—but I’m, you know, if they try to come after us, they know that I respond confidently. They leave me alone, ’cause like, "I don’t know what that guy’s capable of," you know? But it’s the whole concept that if you are prepared for any setting in life—whether it’s negotiations or whatever it may be, dealing with difficult situations—if you’re prepared for those things, there’s absolutely no fear, right? There’s absolutely zero fear in approaching those things because you have your ducks in a row from the perspective of being able to answer that fight—to win it.

What about leverage? Yeah. Can you speak to, like, what these days—I guess the question I have, Tessina—is what leverage do dentists really have when it comes to negotiating with insurance companies?

Tessina Bullock: Yeah, that’s a really hard one to answer. In this day and age, dentists sadly are actually losing some leverage. And it’s really important that we know what that leverage is. And for insurance companies, they actually need us more than we need them. So your leverage for the insurance companies, for negotiations, is be prepared to be a non-restricted provider—an out-of-network provider. That’s where your leverage comes in. Because these insurance companies, even though they will bully you and toughen you up and say, "No, we’re not giving you any increase in fees," that’s because they already have you, right? So you don’t have any leverage ’cause they already have you.

So that’s really the only leverage we have right now. There’s the other leverage that consultants have. If you were to come to Ben or I, or another firm that does negotiations, we have a different type of leverage where we are able to see from a third-party view what fees they’re providing to other offices in the area.

And you’re not allowed to do that as a dentist yourself or as a solo practice or as a group practice because that would be illegal—to know what the other providers are getting. But it’s not illegal for us. We do all the negotiations in the area. We’re able to see what other fees are being handed out. So we can say to our good friend Mary, who we work with every day, we say, "Mary, you know that that’s not fair. You know that Dr. So-and-so next door is getting this better fee schedule and that’s hurting my doctor." And Mary’s like, "Yeah, okay, here’s that fee schedule." So we have a lot better leverage than the doctor does on their own.

Ben Tuinei: Yeah, I mean, you bring up a couple of good points. It’s illegal for doctors to share fee schedules with the intent to use them as leverage to negotiate fees. I think antitrust calls that a conspiracy to raise fees, you know? And I’ve seen that play out. In fact, if you Google "antitrust in dentistry," you find the American Dental Association’s pamphlet on what they call antitrust in dentistry in general. And it’s very clear, and there are court cases against dentists and groups of doctors. The courts have really established the fact that sharing fee schedules—even if it’s your standard office fees—with the intent to raise them, and this is where the PPO negotiations come in, when you share fees collectively with the intent to raise them, that’s against

Tessina Bullock: Yeah, the key word you said there is the face. So insurance companies need to believe and understand that that is coming from the dentist himself. The contract with the insurance company is between the dentist and the insurance company. So if an office manager or treatment coordinator is going in, negotiating—and they can do this on behalf of the doctor—but it doesn’t appear as any real threat to the insurance company because they don’t have any legal standing to actually terminate that contract, which again goes back to that leverage we talked about, which is the only leverage that you have, aside from using a consulting firm.

So if they know that it’s coming from the doctor, and the doctor is frustrated and the doctor is upset with those fees, that doctor has the ability to cut that contract. And so the insurance representative is gonna be much more careful and much more willing to please that doctor. So even if you have your manager helping you prepare the documents, prepare your profile, prepare the letters—make sure you are the one signing those letters, that you are aware and that you’re on board with the plan if things go south.

Ben Tuinei: Yeah, I like that. You know, it’s very rare these days for doctors to actually get involved in negotiations, which I think is a big misstep. But I think the insurance companies know that. They know the reason why doctors can’t do it all in a practice setting—’cause they’re very busy doing what they love and doing what their purpose is, which is treating patients.

In my opinion, I think that the insurance companies have taken advantage of the doctor’s true purpose, right? By ignoring components that help doctors give good quality care to patients. And so when the doctors do get involved, I agree with you—it kind of changes the dynamics. And the numbers prove that, right? Unless you’re using a professional firm. You know, professional firms do this for a living, and this is all—like, most companies like ours—that’s all we do is negotiate.

So I was gonna ask, is it better to try it on your own or hire a professional? And I don’t want to come off as giving an answer that’s one-sided. I think professional firms and doctors as well are capable of achieving the same results when you negotiate, if you follow the right steps.

That is—what about—yeah, like when you’re nego—any comments on that before we move on?

Tessina Bullock: Um, no, I just—I completely agree. I think dentists, if the office is using the correct tactics or steps, right, then they can be successful at it. It can be much harder. Sometimes it can take a little bit longer. There is something to be said about expertise. A general dentist can do a root canal, but is a patient gonna have a different experience going to an endodontist specialist? That’s why we have specialists, right? So there’s just something to be said for that. Can you do it? Yes. Can you do it well? Yes. And can the end result be similar or even the same? Possibly. But sometimes, in some situations, it is better to go to the specialist.

Ben Tuinei: Love it. Love it. What about, when it comes to like the part when you are actually negotiating with these insurance companies, what should you sort of pay attention to when it comes to like reviewing a first fee offer? Let’s say you get a proposed fee increase, and normally you would expect that that fee increase is not gonna be all that great, right? That’s just how the game works. What should you pay attention to when you get that first fee increase offer?

Tessina Bullock: Yeah, it’s very important to pay attention to your most utilized codes, but also the corresponding downgrades to those codes. I still run into a lot of practices that think they’re supposed to write off to the downgraded allowed amount. Please don’t be doing that. Make sure that you’re only writing off to your higher code—your non-downgraded code.

However, that means the patient, though, is paying a much larger balance out of pocket if we’re not watching those downgrades. So it’s not that necessarily the office is gonna suffer tons, but your patients are suffering. So do your due diligence, take some time, look at those downgrades, and make sure that we’re negotiating those as well—to help our patients not have to pay such a heavy out-of-pocket difference.

Ben Tuinei: Yeah, that’s a good point. ‘Cause this is actually the number one area that’s ignored when you’re negotiating fees—are the downgrade or alternative benefits. And I mean, I’ve seen crowns go up like 40%, but the downgrade of choice is not negotiated, and it’s—you know, the out-of-pocket difference for the patient could be several hundred dollars more than the standard copayment, as if the doctor actually placed the downgrade code as the actual procedure, right?

And so that’s really good advice—that even though you might not carry amalgam or may not seat PFM crowns, it’s still important to look at those downgrade alt codes to get them raised. And then the other thing is that a lot of people say, "Well, if we negotiate fees, that’s gonna influence patients to reach their annual maximums quicker."

One statistic to remember is that only 37% of adults—which is the bulk of the restorative claims that are paid—only 37% actually use their benefits once a year. And only 6% of everybody with a PPO plan actually reaches their annual max. So that component of raising the alternative benefits, to what Tessa mentioned, to help reduce the patient’s out of pocket, is really spot-on advice.

Tessina Bullock: One thing I’ll add to that—sorry, that comment—I get that a lot: "their maximum sooner." Yes, they probably will, because the maximums are not positioned correctly. These insurance companies—we’re still seeing very low maximums of $1,500. Very average maximum. It is not positioned correctly. And until we start showing insurance companies—and having patients and HR departments complain—that that max only covers one crown and one cleaning, we won’t get change until we work towards that change, right?

Ben Tuinei: Absolutely. I love it. Great advice there, Tessina.

All right, so we’re getting close to wrapping up. We just have a couple more questions here for you. So I think we have to be very careful with this next question because, you know, the truth be told, we get pursued by insurance companies all the time for what we say on podcasts or what we say in articles. And so we’ve—as bold as I want to be to tell the insurance industry, "We don’t care, ’cause you’ve never been successful at taking us to court"—but out of respect for the fact that we don’t want our attorneys to get mad at us, we’ll leave insurance companies’ names out.

But I think all the listeners are gonna know what my real question is for you. The question is: are all insurance companies negotiating these days?

Tessina Bullock: Yes, all insurance companies are negotiating these days. Again, depending on your leverage—what you are leveraging in order to get those negotiations—it is possible to get all insurance companies to negotiate.

Ben Tuinei: Yeah, you and I dealt with this at the beginning of 2025, and we learned through that process that a lot of these insurance companies that traditionally hold a non-negotiating stance—they do negotiate. And so the big thing is, if you are dealing with these insurance companies, give us a call, talk to us about it. That way you can at least talk to somebody—people like Tessa and I and our team members—where we have success negotiating with every single insurance company out there. It’s just all about area and what leverage dynamics you can find, right?

Last thing I want to mention—Tessa, at least ask you—is: what about umbrella strategies? Like what you mentioned in the beginning, building the insurance profile and understanding how are you credentialed with these plans, right? Who are your umbrella networks? Are umbrella network strategies—are they helpful? I mean, people talk about them all the time, but a lot of doctors are skeptical. Are they truly helpful in terms of negotiations and getting a better schedule of fees from these insurance companies?

Tessina Bullock: Yes, definitely. A lot of doctors have a very negative experience with umbrella companies because they have several contracts and several umbrella companies, and contracts with insurance companies that have also started leasing their fees. Leasing is another word for our umbrella networks, right? So they have a very negative experience of it: “Actually, it lowered my fees,” or, “I tried to go out of network and somehow got put back in network,” and they feel like these insurance companies are just doing whatever they want with, you know, no cares. And it can become a very frustrating experience.

But again, if you’re talking to specialists or masters in this department who know and understand that spiderweb—I call it the web of the umbrella networks—we can really help untangle it and get it dialed into where you’re able to get the highest possible fees with the fewest amount of contracts. That means less contracts to watch out for, less contracts to negotiate every two years, more freedom in picking and choosing which companies you want to be in-network with versus out-of-network with.

So yes, it’s a huge strategy. It’s becoming more and more common knowledge these days, but it still is not common enough. The word is being thrown around, people are hearing it, and they’re starting to see it—like I said—in a negative aspect. But the true understanding of it is still being fulfilled for many offices.

Ben Tuinei: Yeah, I think it’s a pain point because the umbrella networks can be implemented very successfully if you know how they work. You know how to troubleshoot the problems. And I think when I’m looking at the chat forums online, it’s interesting that the advice people give about how to solve these solutions—a lot of those pieces of advice are incorrect.

Tessina Bullock: Oh yeah, I’ve seen that.

Ben Tuinei: You need to find the right people that know how to solve those problems. And I mean, I can’t be too biased with this, but I think, you know, Tessa, you know this stuff very well. So, a leading candidate here in terms of any of you that are having umbrella network problems—one of which is like, I hear this every day: “I dropped DenteMax and MetLife was through DenteMax, but I’m still getting paid DenteMax fees from MetLife.” You call MetLife, and MetLife says, “Not our problem. Call DenteMax.” You call DenteMax, and they’re like, “What are you smoking? We don’t pay MetLife claims. You need to deal with MetLife on that.” That is their problem that they need to fix.

You just get like an endless, endless runaround from these insurance companies. And so, all the more reason to have a good professional…

Closing Thoughts

Tessina Bullock: Yes. Yeah, those are all very solvable problems, right? If you know how to solve them, and if you’re working with somebody who already has mastered that, it makes your life a lot easier.

Ben Tuinei: That kind of brings up another question. And I guess the answer to this question is no, but the question is: can you prevent those problems from happening? And I say no, because when you’re dealing with insurance companies, you have no control of what they choose to do, you know? They can choose to make your life hell. But the solution to that is—you need to make their life equally hell. Zero sum game, as they call it, right?

Tessina Bullock: Yes. There you go.

Ben Tuinei: That’s awesome. Well, Tessina, any closing thoughts as we wrap up today’s episode?

Tessina Bullock: Well, I don’t think so. I think we covered a lot of really good stuff, but this stuff is always so heavy, right? There’s so much information, there’s so much knowledge. There are so many tricks and tips of the trade to pay attention to, but we’re always getting these questions coming in. That’s where you and I try to build a list of those questions and new podcasts. So I just encourage people to keep listening, be as knowledgeable as possible, learn as much as you can, ask lots of questions. That’s my number one thing I always push offices to do. Don’t just do what the insurance says, right? Push back, ask questions, stand up for yourself.

Ben Tuinei: That’s right. That’s right. And have good partners as well. And I can tell you, when it comes to all things insurance, I want our listeners to know that, you know, Tessina would be a great partner to have to troubleshoot just about any insurance-related problems. So if any of you want to get ahold of Tessina, visit her website: verusdental.com. That’s www.verusdental.com.

She provides a service for insurance verifications, which is a big service that she provides at a good rate because so many practices are understaffed, or their minimum wage laws force them to pay extremely higher rates that—doctors are like, “This is an entry-level position.” And not to say that minimum wage is not helpful for people that work hard, you know, but Tessina has some really great insurance solutions, including PPO fee negotiations.

You can visit her website, or our collective website, which is veritasdentalresources.com, request a consultation, and we’d be totally happy to guide you through this whole complex problem of negotiating PPO fees and dealing with complex umbrella network strategies.

Tessina, thank you for your wisdom today. Always. Thank you for caring for me.

Tessina Bullock: No, thank you so much.

Ben Tuinei: And to our listeners, I want to thank you for joining us today again on another fun and amazing episode of the Insurance Untangled podcast. If you liked today’s episode, give us some love—like it, share it, post it on Facebook. Let other people find our content, especially if you feel like it would resonate with others.

And don’t forget to check out insuranceuntangled.com for our latest. We do have webinars every quarter—we’re having one September 2025 and again December 2025. So check it out and join those webinars. Send us questions if you have them—thank you to those that have.

But until we meet again, folks, we wish all of you the best of success. Take care now.