Silent PPO – Dental News Client Alert
For many years, the ODA has reported on their vigilant attempts to silence the “silent PPO.” Also known as ghost or blind PPOs, these revenue-stealing entities are disallowed in Ohio (Moore, 2015; 2024). Under Ohio law (Ohio Revised Code 3963), PPO’s are prohibited from giving, renting, or selling their participating dentists’ services unless one of the following conditions apply:
- The PPO provides either administrative or claims processing services to an employer or other entity that offers benefits to its employees or members or
- The PPO has an administrative services agreement with one of its affiliates or subsidiaries or
- The actual contract signed by the dentist states that the contract allows network rental agreements and that the PPO intends to sell, rent, or give its rights over the dentist’s services to other PPOs or provider entities. In exchange, the secondarily contracted PPO must comply with the terms and conditions of the original PPO contract with the dentist and follow the original PPO agreements regarding patient lists, timeliness of payment, and manner of reimbursement.
If a PPO rents, sells, or gives its rights to another PPO, the entity must maintain a web page or set up a toll-free number for participating dentists to use that provides access to the lists that the PPO plans to contract with, which must be updated every six months to maintain its accuracy. Providers may not share information about the other PPOs on the list with anyone since this information is considered proprietary.
One of the most irritating aspects of the silent PPO is that dentists and patients find out about its existence only after treatment is done and the payment received is less than anticipated and capped such that the dentist cannot collect any additional monies from the patient. The dentist is forced to offer a discount to the patient that was not anticipated since the dentist was not aware of the relationship between the contracted payors. Remember, silent PPOs intend to take advantage of dentists without their knowledge. Patients have likely been informed by the front staff that the office is not on their list of providers. The dentist is unaware of any obligations to the secondarily contracted PPO and is surprised to receive payments from this unknown entity. The patient is surprised that their original out-of-pocket estimate is suddenly much lower than anticipated.
Two other considerations about silent PPOs are the following:
- The silent PPO is not motivated to steer patients to the dentist, so patients arrive at an office without help from the silent PPO; therefore, the dentist gets no benefit from the relationship with the entity.
- PPOs cannot require dentists to agree with their plan to distribute the dentist’s services to other PPOs; however, with 180 days’ written notice, the plan may terminate a network agreement with the dentist who refuses to participate in future PPO additions, which soils the relationship with the primary PPO.
Dentists should carefully read any contract they sign to protect themselves, looking for suspicious language. Contract language that indicates the PPO can “assign” the agreement “at any time” with all its rights and privileges to affiliated companies is a red flag that should cause dentists to pause and think through the agreement more carefully. If in doubt about contract language, consult an attorney or use the ODA or ADA contract analysis services to help you understand the contract better. The ODA offers this service free of charge. Use the contact information below to learn more.
If you think you have been disadvantaged by a silent PPO, contact the ODA via email at dentist@oda.org or call (614) 486-2700.
References
Moore, C. (2015, Apr 13). Leased PPO networks and silent ppos. ODA.org. https://www.oda.org/news/leased-ppo-networks-and-silent-ppos/
Moore, C. (2024). ODA working to ensure silent ppos don’t become a thing in Ohio. ODA Today. ODA WORKING TO ENSURE SILENT PPOS DON’T BECOME A THING IN OHIO – Ohio Dental Association
