The PPO Math Many Dentists Never Run

Is a PPO plan quietly costing your practice money? Dr. Allison House explains how her son, a healthcare actuary, finds out.

In Episode 115 of The Authentic Dentist, Shawn Zajas sits down with Dr. Allison House to talk about the insurance contracts many practices feel stuck on, and whether those contracts are actually profitable. This is a general professional conversation, not financial advice.

EPISODE OVERVIEW

It started when Dr. House's son JD, a healthcare actuary, analyzed a dentist whose practice was more than half Delta, with some fees sitting at about 35% of his UCR. The dentist could not drop Delta, so JD looked at who was on each plan instead. A low-paying Blue Cross Blue Shield plan full of healthy patients getting $30 cleanings was mostly chair time, and refilling those chairs with higher-paying MetLife patients changes the mix without touching the Delta base.

Shawn names the mismatch: a plan can look profitable on paper, but its members may never need the services that pay well. Dr. House shares her own history with a 2006 crown fee, setting her fees from the hours she needs to produce, doing her own books, and dropping Delta in 2015 after a year of conversations with patients. They close on why a practice has to make a profit, even though it sounds greedy.

KEY TAKEAWAYS

• Utilization and demographics matter as much as a plan's fee schedule
• When you cannot drop your biggest plan, change the mix
• A plan full of healthy patients getting $30 cleanings can be a loss leader
• What UCR really is, and how to set fees from the hours you need to produce
• How to drop a plan: a year of conversations, no letters
• Know your numbers: ask your bookkeeper how things are categorized
• It is always people first, but you do have to make a profit

WHERE TO LEARN MORE

Dr. House's son JD runs House Actuarial: houseactuarial.net. She also suggests looking at the ADA information on what a healthy practice looks like in terms of percentages, then sitting down with your bookkeeper.

ABOUT THE HOSTS

Dr. Allison House leads House Dental in Phoenix, Arizona, where she practices comprehensive, diagnostic-first dentistry for complex cases. Shawn Zajas helps people find what is truest in them and then build it; he hosts Wholehearted with Shawn Zajas and helps founders turn their podcast into a marketing engine. Learn more at shawnzajas.com.