What’s happening with out of network insurance benefits?

Naren Arulrajah: Hello everyone. Welcome to another exciting episode of the Insurance Untangled podcast. I am Naren Arulrajah, one of the co-hosts of this podcast, dedicated to helping practices that are tangled up with insurance. Get out of that mess. Yes, I use the word mess. We talk about topics that help you take more control and create a bigger future for you, your patients, and of course, your team members. Today, my guest is my dear friend and someone I look up to because he’s a subject-matter expert when it comes to dealing with this messy insurance company, Ben Tuinei. Hey, Ben, how are you?

Ben Tuinei: Hey, Naren. Really good. Thank you. It’s great to chat with you today.

Naren Arulrajah: Thank you, Ben. So the topic we are gonna be covering today is: What’s happening with our out-of-network insurance benefits? Are they getting better, or are they getting worse? I think it’s a wonderful topic, Ben. Would love to dive in. Let me start by asking you the first question that I have for you. So the topic again is: What’s happening with out-of-network insurance benefits? Are they getting better or worse? With so many doctors going out of network these days, how are insurance companies responding to out-of-network benefits?

Ben Tuinei: That’s a great question there. You know, it’s interesting that everybody knows—the doctors, the insurance companies, and now the employers and patients—know that there’s this trend in dentistry where doctors are fleeing their in-network agreements, right? So there’s questions being asked about that. Like, employers are asking, "Why are we getting notices every day, every week? There are doctors that are leaving the network." And you know, as employers start to investigate this, they start to realize that they cannot reduce out-of-network benefits for their employees if the provider networks are diminishing.

What you’re seeing is that employers are beefing up out-of-network benefits. They’re investing more, or at least asking the insurance companies to invest on their part—keeping premiums where they’ve been, you know, with the standard slight increases, but making access to care easier for people, right?

Ben Tuinei: So that we don’t have this situation where, you know, a common theme is, "Well, I have insurance, but I can’t even use it because I can’t see a provider—nobody’s in network in my community." So this is more of a public concern. In-network, unfortunately, is synonymous with access to care. The regulators, as well as the insurance industry, are feeling pressure to eliminate the access-to-care concerns.

Kind of like the old indemnity days, right? In the sixties, seventies, and eighties, you could see any dental practice with your dental plan, regardless of whether they were in network or not, and you got a similar reimbursement no matter where you chose to go. Well, the good news, Naren, is that we’re seeing those indemnity plans start to resurface.

So, as it pertains to going out of network, you will see some resistance from insurance companies encouraging employers to reduce out-of-network benefits, but the employers don’t want to do that. Because what that does is it eliminates options for their employees, right? So right now, what we’re seeing trend-wise is out-of-network benefits are increasing—they’re getting better—primarily to address the fact that soon, very few doctors will remain in network with certain PPO plans.

So the employers need to make benefits attractive enough, or at least strong enough, to give people the choice to go anywhere they want—in network or out of network. Right? So that’s what we’re seeing.

Naren Arulrajah: Thank you so much, Ben. I think this is awesome, right? Finally, people are taking control. I mean, when you look at the insurance record, there are multiple parties. The insurance company—and the way they make money is they collect premiums, and they keep as much as possible and then give the doctors a tiny piece, right? That’s how they make money. So they make it hard for the, you know, the patients. They make it hard for the doctors, right?

The way they make it hard for the patients is they deny claims. So you show up five months and 29 days after your last cleaning—denied, right? The way they make it hard for the doctors is, you know, many, many claims they don’t approve, and they don’t pay on time, and they don’t let you set your fees, and they control your fees.

Naren Arulrajah: And even then, like, they only pay part of it. And people are like, sick and tired of it. And I’m so glad dentists are rising and saying, "Enough. This is nonsense. I’m not taking this anymore." But the good news—the silver lining in all of this—is there is still this client relationship. Insurance companies must listen to employers because they’re writing the checks. They don’t listen to the patients. They don’t listen to the doctors. But they have to listen to the employers. And employers must listen to their employees.

Like, why would I spend a thousand dollars buying insurance plans if my employees hate the plan? It doesn’t make sense, right? Like, you know, I’m taking my money that I could use to pad my pockets as the business owner, or, you know, add dividends if you’re in a public company, and instead, you know, give it to employees—if the employees hate that plan, right?

Naren Arulrajah: And I’m so glad governments are finally waking up and saying, "We are gonna listen to our voting public," who happens to be the patient. So not the three insurance companies or ten insurance companies and their CEOs, but rather the millions and millions and millions of patients in their states—and of course, in the country and so forth, right?

So I’m so glad it’s opening up, Ben. Thank you for sharing this. And I think maybe it’s like a point of no return. It’s just—the floodgates have opened, and now it’s just a matter of pushing it through, right? I know for a long time they were manipulating you and all that nonsense. But with the internet and information at our fingertips, and people organizing—especially doctors—and like, the Reducing Insurance Dependence community has 1,500 doctors. I mean, literally, they’re all reducing insurance as we speak. They’re dropping one plan, two plans, three plans a year, and just getting rid of this menace.

So it’s really, really nice to hear, Ben. Thank you for sharing this. Let me ask you question number two: What’s your prediction on what out-of-network benefits will look like in two to five years, ten years? I would love to hear that.

Naren Arulrajah: Let me ask you question number two: What’s your prediction on what out-of-network benefits will look like in two to five years, ten years? I would love to hear that.

Ben Tuinei: Absolutely. So because of the economy being somewhat slow, right? People aren’t spending as much as they used to on elective things. Like, the case of soda—that ten years, six years ago, people would buy a bunch of them, but now people have no choice, they can’t afford it. So discretionary spending is somewhat down in certain income categories.

So because of that, you’re seeing far less case acceptance, right? That trend has continued since 2020. It’s getting better, but what you’re finding these days is that there’s a money concern among most residents. So naturally, the insurance industry looks at that as an opportunity to mess around with out-of-network benefits.

There are several insurance companies I won’t make mention of on the podcast, but last year they tried to lower benefits. What backfired on that? It didn’t stop the rate of doctors going out of network, right? All that did is it produced an enormous amount of complaints against the insurance companies in general. "Why would you make that recommendation to give us a plan design that we can’t even use? Because everybody’s out of network in our community," right?

And so this is my warning to the insurance people that listen to this podcast: be very careful about lowering benefits. You are not representing your employers with that fiduciary responsibility that you’re supposed to. And I think time will tell, right? Where the insurance companies are going to continue to feel complaints for not taking care of their clients by abandoning the provider networks, in terms of making it very difficult for doctors to say, "Yeah, I will stay in network."

So two to five years from now, what we’re gonna see, Naren, is out-of-network benefits—insurance companies are gonna test them. They’re gonna eliminate out-of-network benefits. They’re gonna try to convert to EPO, which gives you no opportunity but to go in network. We saw what happened with that in the HMO world, right?

What happened with that is that doctors stopped participating with HMOs, and subsequently, because of that, the employers stopped using HMOs. So you don’t really see a whole lot of HMO plans throughout the industry these days. Well, you can equate the HMO trend to the in-network trend, because that’s exactly what’s playing out. As more and more doctors are going out of network, there’s more and more frustration among the employers to hold the insurance companies more accountable. And I am so happy to see that that trend is happening.

But there is a contingent of the insurance companies that are resisting. So we’ll see benefits take a dip in the next two to three years in terms of the insurance carriers imposing restrictions on where patients can go, to try to force patients to go in network. That doesn’t work. We’ve already seen that play out in many communities in the past with different plan types. But the insurance companies have to try.

The other thing that you’re gonna see in the next two to—well, I’d say two to ten years—is that because the insurance companies are being forced to pay out more in claims, which means that their bottom line is receding, right? It’s that ever-receding pocket of profitability that they’re going through right now.

So what do they have to do? Well, they’re buying dental practices. And so we all heard about Delta Dental in Wisconsin buying a DSO there.

Ben Tuinei: Well, that’s not the first time an insurance company has purchased a group practice or a dental practice in general. This has been going on for the last 15 years. But we’re gonna see more of that happening. And then I predict that the government’s gonna get involved and say, "This is a conflict of interest. How can you write insurance policies and then control dental practices at the same time?"

So anyway, in the end, Naren, when we look at the ten-year outlook, the fee-for-service model is—it’s coming back right now. And it’s one in which the vast majority of the docs want to do. And so the insurance industry is in sort of a freakout mode to prevent that from happening. And the only way they’re gonna do that is to eliminate out-of-network benefits, which fortunately, the employers are not allowing to happen.

So in ten years, it’s very likely that the indemnity style of dental plans will return for good, which means you could use your dollars—your benefit dollars, your insurance dollars—you could use them no matter where you go. Right? That’s my prediction: that those types of plan designs will return sometime very soon.

Naren Arulrajah: Thank you so much. So what I’m hearing you say is, the ones who are trying—I mean, it’s like this, what’s the quote, right? "You can fool some people sometimes, but you can’t fool all the people all the time." I think what has happened is doctors are organizing, thanks to the internet, thanks to Facebook groups, thanks to all these tools. They have WhatsApp and you name it. Like, they’re like, "Enough is enough. I’m not taking this nonsense anymore."

And really, even though they’re individuals, they have power as a group. And like I said, RIDA has 1,500 members—Reducing Insurance Dependence Academy. So it is working, and I think it’s just—you can’t change the tide anymore.

So if I were to kind of give you my two cents based on everything you just told me, I think those who try to take advantage of the doctor and try to create all this nonsense and pay differently for in-network and out-of-network will lose customers. Because the employees will say, "Forget it. This is a garbage plan." Nobody’s—30% of the doctors or 20% of the doctors are in network. Why would my patients go here?

I mean, the whole reason they’re coming here is they have choice. I mean, this is, again, the U.S.—United States of America, right? Meaning it’s all about choice. This is not communist China where you’re told, "Thou shall go to this doctor or else." That doesn’t work, right?

And especially in a world of Google reviews, right? Would I go to a doctor who sucks just because he’s on my plan? No way. They won’t do it. In the old days, there were no Google reviews, so yeah, I don’t know—maybe they’re all equal. They’re not equal. Somebody is amazing, and I want to go to the amazing guy. And if my insurance doesn’t cover it, I’m gonna have a conversation with my insurance administrator.

I’m gonna say, "The three people who are covered have 2.3 Google reviews. Why would I go there? Would you go there?" Then the employer says, "Why am I giving a million dollars to this insurance company who doesn’t cover the good doctors?"

And the good doctors know they can’t do good dentistry if they’re getting paid peanuts—like 40, 50% of what they produce. So I get it. I understand why this is happening now. Before, there were no Google reviews, so you didn’t know—everybody was the same. Now it’s not. Everybody’s not the same, right?

Ben Tuinei: Yep, yep. No, I agree.

Naren Arulrajah: Let me go to the next question. Does the change in out-of-network benefits build a more solid case for doctors to go out of network? That’s a great question.

Ben Tuinei: Absolutely. Yeah. So I think that’s the money question for this episode—is should you consider going out of network, right? Or is the industry setting you up for better success as you transition towards out of network? And the answer to that is yes.

Like what you just mentioned, the employers are finally paying attention. They’re calling out their insurance companies, and they’re firing them. Right? So imagine if you have Delta Dental and you fire Delta Dental, and then you pick MetLife. And MetLife knows that you fired Delta Dental for the reasons that they have a diminishing provider network. And MetLife is looking at this thinking, "Well, our provider network is way smaller than Delta Dental."

So how are we going to structure benefits?

And the answer to that, from an insurance perspective, is: we need to make sure that the out-of-network benefits are generous so that we don’t get complaints from our employer that our patients can’t go to many practices. Right?

Ben Tuinei: They can use their benefits no matter where they go. And so, in terms of out of network, the question on is there a stronger case to go out of network these days?—the answer to that is yes.

Why is the answer yes? Because in the last five years, that’s been the trend—doctors have been going out of network in the thousands, and that’s already shown to be very beneficial for the doctor community, right?

In terms of your insurance contract, it is now significantly more favorable for doctors to go out of network, for the reasons that we mentioned, right? But it is also true that the out-of-network trend has increased the ability to negotiate for those that want to remain in network. But those that are still in network are still having a hard time negotiating fees.

What I’ll say about that is—with the right experts—what you do tend to find is that there are more strategies, there are higher fee increases that are available. You just need to get the right people involved. Kinda like what Naren says on his episodes: when you have the right partners, you do tend to find that you can seize on these opportunities based upon where the current trends are heading.

Naren Arulrajah: Can you expand on that? What kind of partners are you looking at? I know marketing is a key piece, and of course we would love to help. But outside of marketing, what are the partners you think could help you with this, Ben?

Ben Tuinei: Absolutely. I mean, I would say an insurance partner—outside of marketing, of course, for new patient flow, which is a really great resource there. But as it pertains to out of network, Gary Takacs is one of the best in the industry.

I would follow the Facebook page that you mentioned, right? The I Love Dentistry Facebook page. Yeah. So go to those and—

Naren Arulrajah: We’ll put a link to I Love Dentistry, right? So we’ll create a link there and we will definitely start sharing information. Yeah, so that—and you’ll get tons of resources. Join the Reducing Insurance Dependence Academy, right? So go to RID.academy. There’s a conference coming up.

So those are all awesome resources and awesome communities. And I’m gonna be blunt, Ben, you are an amazing resource. You know so much about dealing with this nightmare called insurance—more than anybody else on the planet, right?

So, if somebody is interested in getting ahold of you, Ben, how can they do that?

Ben Tuinei: Well, thank you for that plug there. And yeah, visit our website: veritasdentalresources.com.

What we normally do is an assessment on PPO negotiating and contract strategies. When we get into the out-of-network stuff, Gary Takacs is my man—I love him, I love his education, I love how he teaches out of network. And quite frankly, to me, he’s one of the best in the industry in terms of patient retention and growth.

But if you need an assessment on PPO fees, check out veritasdentalresources.com, and we’d be happy to give you a PPO assessment.

Closing Thoughts

Naren Arulrajah: Thank you. Yeah, thank you, Ben. Last question before we wrap this up: What is your recommendation for doctors who are uncertain if they should go out of network but really want to head in that direction?

Ben Tuinei: You know, I think—I honestly think that consulting with a professional, kinda like what I mentioned with regards to Gary Takacs, do a consultation with him and his team in terms of an assessment on out of network. You know, like what we talk about with the marketing strategy meeting—that’s another one to do. Go to insuranceuntangled.com/msm, do a marketing strategy meeting to kind of look at your marketing dynamics before you go out of network.

Because when you go out of network, you may lose new patient opportunities. Naturally, in-network practices have an ability for organic growth. So marketing is a key one.

In terms of straight out of network, maybe we can post a link to book a meeting with Gary. Yeah, I hear consistent feedback every single day about how those types of consultations really do help a doctor understand—or at least address—the questions of uncertainty and fuel that with hope and confidence.

When you look at the realities in your practice numbers, and what things could look like if you go out of network, Gary and his team are among the best in the industry to do that type of assessment.

Naren Arulrajah: Thank you so much, Ben. Really enjoyed this conversation. And I also want to take a minute to thank our listeners. You know, without you, we wouldn’t be able to do what we are doing.

So if you want to learn more, go to our YouTube page, go to the insuranceuntangled.com website. And by the way, if you want to book a meeting with Gary Takacs, go to thrivingdentist.com. So that’s one word: thrivingdentist.com/csm for a Coaching Strategy Meeting—CSM.

You know, Gary is a blunt person. Once you meet him, you’ll know. If he thinks you should go out of network, he’ll tell you. He’ll tell you what steps you need to take, and you’re ready to go. If he thinks you’re not ready, he will tell you that too.

But I do think, like Ben said, you really need to think this through—because if you don’t do it right, you can be in a whole heap of trouble.

Ben Tuinei: Right?

Naren Arulrajah: And also, don’t forget to go to the Reducing Insurance Dependence Academy website—RIDA Academy—and we have an event coming up, a huge summit on October 24th. Sign up for it. It’s five hours of CE, and we are giving it all away. So pretty much, the Insurance Untangled program is sponsoring you. So go there and sign up.

Thank you, everyone, and thank you, Ben, for a wonderful episode. And till we meet again, have a wonderful rest of the week.