Going Out of Network with Dental Insurance Carriers

Thinking About Going Out of Network? Here’s What to Check First

If your dental practice has ever wondered whether it’s time to go out of network (OON) with certain PPO plans, you’re not alone. Many offices are discovering that deep write-offs and administrative headaches often outweigh the benefits of network participation.

But leaving a PPO shouldn’t be an emotional decision — it should be a data-driven, strategic move backed by solid financial insight.
Below are the key metrics and considerations to review before making the leap.

1. Review Your Fee Schedules

Start by running a report that compares your full fee to your adjusted PPO fee schedule.
Many practices are surprised to see carrier adjustments exceeding 30–50% of their standard fee — that’s a direct hit to your profitability per procedure.

Plans with the largest write-offs often signal a need for renegotiation or potential exit. If the reimbursement doesn’t cover your true costs or match the quality of care you deliver, it’s time to evaluate alternatives.

2. Evaluate Revenue per Patient and New-Patient Sources

Not all PPO plans perform equally. Analyze:

• Revenue per patient by plan

• Volume of new patients generated by each network

• Which plans primarily bring in low-yield, low-retention patients

Your goal is to identify which plans are actually fueling practice growth.
If a PPO brings minimal new patients and low average revenue per visit, it may not be worth the continued participation.

3. Assess Patient Distribution and Retention Risk

Look at the percentage of patients attached to each plan and estimate what would happen if you dropped it.
Ask:

• How many patients would likely stay?

• How many are loyal to the provider vs. the plan?

• What revenue percentage would you temporarily lose?

This analysis helps you determine whether your practice can absorb the short-term loss while transitioning to higher-value, fee-for-service care.

4. Check Practice Cash Flow and Reserves

Before going out of network, review your cash flow statements and make sure you have enough cushion to handle:

• A temporary dip in patient visits

• Delays in collections

• Extra marketing or communication costs during the transition

A healthy reserve fund acts as your safety net while you adjust to new reimbursement models.

5. Factor in Administrative and Overhead Costs

Going OON isn’t just about reimbursement rates — it’s also about time and efficiency.
Consider the staff hours and resources dedicated to:

• Claims processing

• Appeals and adjustments

• Plan-specific communication

If a plan’s administrative burden outweighs its financial benefit, it’s another clear indicator that it may be time to disengage.

6. Make It a Phased, Strategic Transition

Don’t drop all your plans at once. Use your metrics to create a phased exit plan that:

1. Starts with the lowest-yield PPOs

2. Prepares patient communication scripts

3. Adjusts marketing to attract more fee-for-service patients

4. Monitors KPIs monthly to track progress

By approaching your exit methodically, you minimize disruption while maximizing long-term growth and profitability.

The Bottom Line

By closely tracking your financial, patient, and administrative metrics, your dental practice can confidently determine which PPOs are holding you back.
A well-planned transition helps you regain control of your fees, reduce overhead, and position your practice for sustainable, profitable growth.

Need Help Crunching the Numbers?

Understanding what to review before going OON can feel overwhelming — especially if you’re not sure how to interpret your data or communicate the change to patients.

That’s where Colleen Huff, the Dental Insurance Coach, comes in. With over 25 years of real-world experience, she helps practices like yours:

• Analyze PPO profitability

• Build exit strategies

• Train teams to handle patient communication and billing

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