When (and how) to renegotiate your PPO fees.

PPO fee schedules don't rise on their own. Most practices sign the first offer at credentialing and never look again, while staff, lab and supply costs climb every year. Renegotiating is how you close that gap. It works best when you come with numbers, a specific ask and a written request.

Three numbers to know first.

• Your full fee — what your practice charges, set by you.
• The allowable (also called the contracted fee or MAC, maximum allowable charge) — the most an in-network plan pays for a code. The gap between your full fee and the allowable is your write-off.
• UCR (usual, customary and reasonable) — the amount a plan sets for out-of-network care, based on fees charged in your area, usually at a percentile like the 80th or 90th.

One rule that costs nothing: always report your full fee on claims, even to plans you're contracted with. The ADA recommends it, because payers may use submitted charges when setting allowables. If you submit the discounted fee, you hide the evidence that your fees have gone up.

Signs it's time.

• Two to three years or more since your last review.
• A plan that sends you high volume at a low margin.
• Allowables well below what other plans pay you for the same codes.
• A milestone: a new provider, a new location, or a re-credentialing renewal.
• EOBs showing network names you don't remember signing with (see leased networks below).

Which plans will actually negotiate.

• Commercial PPOs — the main target. Many will review a request, though some only at set windows such as contract renewal or re-credentialing. Results vary by plan and region.
• Medicaid — rates are set by the state program, not negotiated with provider relations.
• DHMO / capitation plans — capitation rates are fixed in the contract. Revisit them at renewal.
• Leased networks — your contract may let a carrier lease your discounted fees to other networks, so a patient's plan can pay you a rate you never agreed with them directly. Ask each carrier whether it leases its network and whether a new fee schedule carries over to leased networks.

The negotiation, step by step.

1. Get your current fee schedule in writing. Request it from each plan's provider relations team or portal. You can't negotiate rates you haven't seen.
2. Rank your plans. For each plan, pull your most-billed codes, how often you bill them, the current allowable and each code's share of revenue. Start with the plans where volume times gap is biggest.
3. Benchmark. Compare each allowable to your full fee, to what other plans pay you for the same code, and to regional fee data such as the ADA's Survey of Dental Fees.
4. Build your case. Note how many of their members you see, appointment availability, how few in-network dentists are nearby, rising costs, and how long it's been since your last increase. Mention the efficiencies you already offer: electronic claims, EFT and online eligibility checks.
5. Send a written request to the regional provider relations manager, with specific codes and a specific ask (template below).
6. Follow up. Expect weeks, not days. The first counteroffer is rarely the best one. If the final number still doesn't work, weigh whether staying in-network with that plan makes sense — see what going fee-for-service actually changes.
7. Document and verify. Keep the signed amendment, update the fee schedule in your practice management software, and check the next EOBs to confirm the new rates are being paid.

Negotiate on your own behalf only — between your practice and the plan. The ADA's guidance is explicit that this shouldn't be done with or on behalf of other dentists.

A fee review request letter you can adapt.

Subject: Fee schedule review request — [Practice name], TIN [number], NPI [number]

Dear [Provider relations manager],

[Practice name] has been an in-network provider with [Plan] since [year], and we currently see about [number] of your members each month. Our contracted fee schedule was last updated in [year].

Since then, our costs for staff, lab work and supplies have risen significantly, and our allowables for our most frequent procedures now sit well below [regional benchmarks / what comparable plans pay]. The attached summary lists those codes, our current allowable amounts and the rates we are requesting.

We value caring for your members and want to continue. We'd welcome a review of our fee schedule and are glad to discuss it by phone.

[Name, title, phone, email]

Attach a one-page table: CDT code, description, annual volume, current allowable, requested fee. Keep it to the 10–15 codes that drive most of your revenue from that plan.

After the deal.

• Load the new fees into your PMS so estimates and write-offs are right from day one.
• Check EOBs for the first month. New rates sometimes take a cycle to load at the payer.
• Put an annual fee schedule review on the calendar. The ADA recommends reviewing contracted fees every year.

Where ZenHub fits.

Fee schedule negotiation is part of our credentialing service. We pull every fee schedule, benchmark it against UCR and regional data, and negotiate where the payer allows it — at initial credentialing and at renewals. For what to expect from any partner doing this work, see what to look for in a dental credentialing partner. Want to find your underpaying plans? Book a call.