--- title: "PPO Participation Decision: Data, Contracts and Questions" description: "Dental PPO participation explained: how PPO contracts work, the data to pull, the terms to review and the questions to ask before joining, staying or leaving." url: https://joncopeland.multisites.ai/guides/ppo-participation-decision publisher: Copeland Consulting Services email: drcopeland@joncopelanddds.com contact: https://joncopeland.multisites.ai/contact --- # The PPO participation decision: data to pull, contract terms and questions to ask A dental PPO contract trades a lower fee schedule for network status with a plan. The choice belongs to the practice owner, with an attorney and CPA. This guide gives no advice on joining or leaving. It lists how PPOs work, the data to pull by payer, the contract terms to read and the questions to ask. GuideUpdated October 26, 20268 min read 1. 1 ## No advice on the choice This guide does not tell any practice to join, stay or leave a PPO. It lists factors, data and questions. 2. 2 ## What a PPO is The ADA describes a PPO as regular indemnity insurance combined with a network of dentists under contract to deliver services for set fees. 3. 3 ## Pull data by payer An ADA News column suggests submitting your full fee, then reviewing your most common procedures and write-offs by payer. 4. 4 ## Read before you sign The ADA warns that signing a provider agreement creates legally binding promises, and that plan policies can change unilaterally. 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](https://joncopeland.multisites.ai/guides/dental-practice-management). Related reading: [how to grow a dental practice](https://joncopeland.multisites.ai/guides/grow-a-dental-practice) and [KPIs and benchmarks](https://joncopeland.multisites.ai/guides/dental-practice-kpis-and-benchmarks). For a shorter list of factors, see the post on [PPO participation factors](https://joncopeland.multisites.ai/blog/dental-ppo-participation-factors). ## What is a dental PPO? A [dental PPO](https://joncopeland.multisites.ai/glossary/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](https://joncopeland.multisites.ai/glossary/in-network) and [out-of-network](https://joncopeland.multisites.ai/glossary/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. Factor What to look at Where the data lives Fee schedule Plan allowed fee versus your full fee for common procedures Your fee schedule; plan fee schedule Write-offs Total write-off by payer over twelve months Practice management software Patient mix Share of active patients and of production by payer Software reports Overhead Overhead percentage and break-even production Financial statements, CPA Capacity Open chair time versus network volume Schedule data Admin load Staff hours on verification, claims, appeals Time log, staff input Contract terms Fee changes, utilization review, bundling, termination The signed agreement; attorney Local market Competing practices’ network status, employer plans Local research Patient impact Patients who would need to change offices or pay more Your patient list 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](https://joncopeland.multisites.ai/glossary/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. Entry Content Payer and plan Name, plan type, contract date Data reviewed The seven checklist items above, with the period covered Terms reviewed Fee schedule, change notice, utilization review, termination Advisers consulted Attorney, CPA, state society or ADA contract analysis Decision and owner What was decided and who carries it out Review date When the decision will be revisited ## 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](https://joncopeland.multisites.ai/blog/out-of-network-dental-practice) and [dental membership plans](https://joncopeland.multisites.ai/blog/dental-membership-plans). ## Next step Return to the [dental practice management pillar](https://joncopeland.multisites.ai/guides/dental-practice-management) for the other management topics. Dr. Jon Copeland, DDS, is a general dentist in Wildwood, Missouri. [Contact Dr. Copeland about consulting](https://joncopeland.multisites.ai/contact?topic=consulting). ## Frequently asked questions ### Is a dental PPO worth it? No source can answer that for every practice. It depends on fee schedules, write-offs, patient mix, overhead, local competition and contract terms. A practice can compare production and collections by payer, then ask its CPA and attorney. This guide lists the data and questions but gives no recommendation. ### What is a dental PPO? The ADA describes a dental PPO as a regular indemnity plan combined with a network of dentists under contract to the insurance company. Those dentists deliver specified services for discounted fees under a signed agreement. Contracted dentists must usually accept the maximum allowable fee set by the plan. ### How do you negotiate with a dental insurance company? An ADA News column advises reviewing contracts periodically, negotiating individually, submitting your full fee so write-offs are visible, evaluating your most common procedures by payer and starting with one payer. The ADA offers a negotiation guide to members. Have an attorney review any contract before signing. ### How do you leave a dental PPO network? Follow the termination terms in your signed agreement, including notice periods, and prepare patient communication and staff training. The ADA offers members guidance on terminating a network agreement. Your attorney should review the contract first, because terms vary by plan and state. ### What is the difference between in-network and out-of-network? An in-network dentist has a signed agreement with the plan and accepts its allowed fees. An out-of-network dentist has no agreement. Most PPO plans pay some benefit for out-of-network care, often at a lower level. Exclusive provider plans pay only for network dentists. ## Terms on this page - [Practice management software](https://joncopeland.multisites.ai/glossary/practice-management-software) - [Dental practice management](https://joncopeland.multisites.ai/glossary/dental-practice-management) - [Accounts receivable](https://joncopeland.multisites.ai/glossary/accounts-receivable) - [Overhead percentage](https://joncopeland.multisites.ai/glossary/overhead-percentage) - [PPO participation](https://joncopeland.multisites.ai/glossary/ppo-participation) - [Dental benefits](https://joncopeland.multisites.ai/glossary/dental-benefits) - [Out-of-network](https://joncopeland.multisites.ai/glossary/out-of-network) - [Practice owner](https://joncopeland.multisites.ai/glossary/practice-owner) - [Credentialing](https://joncopeland.multisites.ai/glossary/credentialing) - [Fee schedule](https://joncopeland.multisites.ai/glossary/fee-schedule) ## Sources 1. [American Dental Association: Types of Dental Plans](https://www.ada.org/resources/practice/dental-insurance/dental-plan-overview) 2. [American Dental Association: Dental Insurance 101 (PPO Plan Basics), updated 11/10/2021](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/practice/dental-insurance/ada_dental_insurance_101_ppo_plan_basics.pdf) 3. [American Dental Association: An Introduction to Dental Benefits](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/practice/dental-insurance/intro-to-dental-benefits.pdf) 4. [ADA News: Dear ADA, Reimbursement rates (January 2026)](https://adanews.ada.org/ada-news/2026/january/dear-ada-reimbursement-rates/) 5. [American Dental Association: Dental Insurance](https://www.ada.org/resources/practice/dental-insurance) 6. [American Dental Association: Dental coverage, access and outcomes (HPI)](https://www.ada.org/resources/research/health-policy-institute/coverage-access-outcomes) 7. [Overjet: Average Dental Office Overhead, Complete Breakdown by Practice Size (vendor blog, September 2025)](https://www.overjet.com/blog/average-dental-office-overhead-complete-breakdown-by-practice-size) Written by Copeland Consulting Services and checked against the sources above on October 26, 2026. Rules, data and guidance change, so check the linked page before you act on it. ## Keep reading - [Dental PPO participation: factors to weigh before you signJoining a dental PPO means agreeing to the plan's fees and rules in return for access to its members. The ADA advises reading and evaluating the contract fully before signing. Weigh fee levels, payment terms, plan rules and cash flow, and ask an attorney and CPA to review.](https://joncopeland.multisites.ai/blog/dental-ppo-participation-factors) - [Out-of-Network dental practice: what it means for patientsAn out-of-network dental practice does not hold a participating agreement with a patient's dental plan. In a PPO the patient may pay more but still get a benefit. In an EPO the plan pays no benefit. Practices should explain this to patients and check billing rules with an attorney.](https://joncopeland.multisites.ai/blog/out-of-network-dental-practice) - [Dental practice KPIs and benchmarks: formulas, sources and limitsA dental practice KPI is a number the team tracks on a schedule, such as collections, overhead percentage, no-show rate or case acceptance. Few KPIs have an official benchmark. The ADA publishes survey averages for income and billings. Most other benchmarks online come from vendors, and formulas differ, so compare your own trend first.](https://joncopeland.multisites.ai/guides/dental-practice-kpis-and-benchmarks) - [Dental practice management: people, money, schedule, patients and complianceDental practice management is the business side of running a dental office: finances, scheduling, patient communication, insurance decisions, team systems and legal compliance. Track a few core numbers, build written systems, review them on a set schedule, and use federal and ADA sources for compliance basics.](https://joncopeland.multisites.ai/guides/dental-practice-management) - [How to grow a dental practice: a systems guide with sourcesPractice growth comes from a small set of measurable systems: new patient flow, patient retention, schedule use, payer mix and overhead. Published data shows national demand is limited, so most practices grow by keeping patients, filling the schedule and reading their own numbers monthly. This guide lists each lever, how to measure it and what sources say.](https://joncopeland.multisites.ai/guides/grow-a-dental-practice) - [How dental membership plans work for practices and patientsA dental membership plan, also called an in-office plan, has patients pay a fixed amount monthly or yearly. In return they generally get preventive care at no charge and discounts on other work. The ADA offers a toolkit for evaluating it, and state rules vary, so involve an attorney.](https://joncopeland.multisites.ai/blog/dental-membership-plans) ## Talk with Dr. Copeland [Contact Dr. Copeland](https://joncopeland.multisites.ai/contact)[Email](mailto:drcopeland@joncopelanddds.com)