PPO Participation can shift frequently, here’s the most recent participation shift and how it could be affecting your practice.

Guardian is exiting the group medical insurance market and has reached an agreement with United Healthcare to renew coverage for Guardian clients. Guardian stated this move will not impact Guardian’s non-medical product lines, like Dental.

Guardian and United Healthcare have since entered into a leasing agreement to share dental providers. If a provider is directly contracted with Guardian and UHC, those relationships are primary and the leasing arrangement does not affect you. Dental practices who are directly contracted with only Guardian OR with only UHC could see a shift in how they participate.


What does this mean for your practice?

For example, if a dental provider is directly contracted with UHC but not otherwise directly contracted with Guardian, the provider may be out-of-network with Guardian patients or they may be in-network with Guardian patients under another contract (e.g. Aetna or under the Connection umbrella network).  With the new relationship between Guardian and UHC, a provider’s participation with Guardian could shift to UHC. In this instance, the provider may potentially now be reimbursed when treating Guardian patients via their UHC fee schedule.

If you are not directly contracted with either UHC or Guardian, this relationship will not affect you. A good way to identify shifts in participation is paying close attention to EOBs. Any time a claim is re-priced, or processed through a leasing arrangement, the EOB will state which direct contract they are accessing you through. So if you were out network with UHC prior to January 1, but are direct with Guardian, check your UHC EOBs to see if those patients’ reimbursements were processed according to your Guardian fees. The UHC EOB will specifically say the fees were adjusted based on your Guardian contract and should align with your current Guardian reimbursements.

Unitas clients should notify their Practice Representative if they notice any shifts in their participation. Not a current Unitas client, and worried about this upcoming PPO participation change? Reach out to us today to see how we can help you untangle this ever-growing PPO web.

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