The PPO participation decision: data to pull, contract terms and questions to ask

Whether to join, stay in or leave a dental PPO network is a business decision for the practice owner. This guide gives no advice on that choice. It explains how a PPO contract works, what data to pull, which terms to read and which questions to ask. It is general education from Copeland Consulting Services. It is not legal, tax or financial advice. Involve your attorney and CPA, and consider the ADA contract analysis service if you are a member.

It belongs to the dental practice management pillar. Related reading: how to grow a dental practice and KPIs and benchmarks. For a shorter list of factors, see the post on PPO participation factors.

What is a dental PPO?

A dental PPO is a plan that combines indemnity insurance with a network of contracted dentists. The ADA describes it as “a regular indemnity plan combined with a network of dentists under contract to the insurance company to deliver specified services for discounted fees in accordance with provisions in the signed agreement.”

Key points from the ADA’s plan overview:

• Contracted dentists must usually accept the maximum allowable fee set by the plan.
• Non-contracted dentists may have fees higher or lower than the plan allowance.
• Patients can usually see either a contracted or a non-contracted dentist, but a non-contracted visit may bring a smaller benefit.

In-network and out-of-network status are therefore about the contract between the dentist and the plan. See in-network and out-of-network.

How common are PPOs?

PPOs are the most common plan type. An ADA fact sheet updated in November 2021 cites the National Association of Dental Plans: about 263 million people had a commercial or publicly funded dental program in 2019, and 85% of commercial dental plans were PPOs. The ADA’s introduction to dental benefits also calls PPOs the most popular type of dental plan in the United States.

These figures are several years old. Data changes. Check current figures from the plan administrators in your area and from your state dental society.

What does coverage mean for who visits a dentist?

Coverage status is strongly tied to dental visits. ADA Health Policy Institute data show that in 2024, 53% of adults ages 19 to 64 with private dental insurance had at least one dental visit, compared to 25% with public insurance and 17% with no dental insurance. For seniors 65 and older, the figures were 76%, 28% and 48%.

That is national data. It does not say how a given practice’s patient base would change if it joined or left a network. Your own patient and payer data answer that better.

What are the factors in the decision?

Factors, not a verdict. Each one has a number or a document you can check.

The ADA’s January 2026 column said that dentists can evaluate their own participation, and that some “thoughtfully consider modifying or ending network participation, always weighing the impact on patients, staff and long term practice sustainability.” The same column adds that periodic review of contracts and individual negotiation are among the steps dentists can take. It is a statement of options, not a recommendation to any one practice.

Which data should a practice pull first?

Start with data you already have. The ADA News column lists tips that map to data pulls: submit your full fee so write-offs are visible, evaluate your most common procedures and what you write off by payer, and start with one payer. A vendor article from Overjet makes a similar point: regular insurance plan analysis helps identify unprofitable contracts. That article is from a company that sells dental software, so treat it as one view.

Use this checklist:

1. Twelve months of production, adjustments and collections by payer.
2. A list of your 20 most common procedure codes, with the plan allowed fee and your full fee for each.
3. The number of active patients and new patients by payer.
4. Cancellation and no-show rate by payer, if your software tracks it.
5. Staff time spent on claims, appeals and verification by payer.
6. Your overhead percentage and an estimated break-even production figure from your CPA.
7. The age of each payer’s accounts receivable.

If you post only the contracted fee, write-offs vanish from the reports. Then the data cannot answer the question. Decide how to post fees with your accountant before starting.

What should you read in a PPO contract?

Read the whole agreement, including the provider manual and any policy documents it incorporates. The ADA’s introduction to dental benefits is direct: “When you sign a participating provider agreement with a dental benefit carrier, you make promises that will be legally binding on you.” It adds that the other party may be able to terminate the contract or take legal action for breach, and that you may be agreeing to “policies and procedures that can be changed unilaterally by the plan.” It strongly urges dentists to consult a personal attorney before signing.

The ADA also describes utilization review: payers monitor treatment patterns of participating dentists, and dentists who go above the payer’s norm for a procedure may be notified and, if they do not change patterns, may be dropped from the plan.

A reading guide for key terms:

• Fee schedule and how often it can change.
• Whether the schedule applies to all procedures, including those the plan does not cover.
• Bundling and downcoding rules, which the ADA lists among provisions addressed in 2025 state insurance reform laws.
• Utilization review and audit rights.
• Notice for changes, and your right to refuse changes.
• Term, renewal and termination notice.
• Credentialing and re-credentialing duties. The ADA offers a credentialing service.
• Appeal process.
• Missouri law or the law of the plan’s state, and which one governs.

Which questions should you ask?

Questions for the plan:

1. What is the full fee schedule, and how is it set and updated?
2. How much notice is given before changes, and can the practice decline them?
3. How are claims edited, bundled or downcoded?
4. How does utilization review work, and what is the appeal path?
5. What are the termination terms for both sides?

Questions for the practice team:

1. What share of production comes from this payer, and what is the write-off?
2. If patients from this payer left, could the schedule be filled, and how soon?
3. What does the staff time cost in claims work?
4. What would patients be told if the practice left, and who would tell them?
5. What does the ADA toolkit or an attorney say about the contract?

Questions for your advisers:

1. How does this payer’s fee compare with the practice’s cost per hour of chair time?
2. What does the contract allow in the way of audits or recoupments?
3. How should fees and write-offs be recorded for clean data?

What happens to patients if a practice’s network status changes?

Patient cost depends on plan design. The ADA’s PPO fact sheet says most PPO plans allow benefits for out-of-network dentists, while exclusive provider organization (EPO) plans pay only when the patient sees a network dentist. It also says dental offices should always verify coverage. The plan overview adds that patients may receive a smaller benefit when they see a non-contracted dentist.

So a change in network status can affect patients differently depending on their plan. A practice can sort its active patients into three groups: those with a plan that has out-of-network benefits, those with a plan that has none, and those with no coverage. The first group may stay and pay more. The second group may have to leave. The third group may see no change. Counting each group gives a factual picture of patient impact.

The ADA News column also notes that staff should be trained on how to talk with patients if the practice leaves a network. Patient letters, call scripts and billing explanations are worth drafting early, and an attorney should review any notice that refers to the contract.

How can a practice record the decision?

A short decision log keeps the reasoning clear for later review, for a partner or for a buyer.

What does the ADA say about negotiation and exit?

The January 2026 ADA News column says that the ADA cannot directly negotiate rates for individual dentists, and that antitrust rules limit what it can do. It points members to a negotiation guide with step-by-step preparation, sample questions and checklists, to Medicaid fee schedule comparisons and HPI data, and to a guide on how to properly terminate a network agreement. It also says staff should be trained on communications if a practice chooses to leave a network. These are ADA member resources. Non-members can ask their state dental society what is available.

What are alternatives, and where do they fit?

Practices sometimes consider fee-for-service, in-house membership plans or a mix. These carry their own legal and tax questions. The ADA lists in-office plans and direct care agreements among its dental insurance resources, and notes that state law differs. Read more in the posts on the out-of-network dental practice and dental membership plans.

Next step

Return to the dental practice management pillar for the other management topics. Dr. Jon Copeland, DDS, is a general dentist in Wildwood, Missouri. Contact Dr. Copeland about consulting.