Ask a room of practice owners what is squeezing them and the same answer comes back first. In the ADA Health Policy Institute's poll at the end of 2025, more than half of dentists — 55% — named low reimbursement as one of their top three challenges for 2026, ahead of staffing for the first time. A third said they were likely to drop out of at least one network during the year, and by June, roughly one in four owner-dentists already had.
So the question is not unusual. What is unusual is answering it with numbers rather than nerves. Owners who drop a plan often do it on a feeling: the contract that irritates them most, the carrier whose fee cut arrived last. Owners who keep a plan often keep it on a fear: the patients who would leave. Both decisions can be made from arithmetic instead, and the arithmetic is not hard. This guide walks through it — what a plan really pays you, how to check one plan in ten minutes, how to compare all of them, what leaving one would actually cost, and how one practice did it.
- The expense that never shows up on your P&L
- Why "should I drop my PPOs?" is the wrong question
- Three terms, so the arithmetic is honest
- The ten-minute check on one plan
- From one plan to all of them
- What leaving would actually cost: the break-even
- Negotiate, drop, or keep
- Out of network is not "we don't take your insurance"
- How one practice did it
- The order of operations
- Run your own numbers
- Sources
The expense that never shows up on your P&L
Rent shows up on your profit-and-loss statement. Payroll shows up. Supplies show up. The largest expense in a PPO-heavy practice never does, because it is not a bill.
It is the contracted write-off: the gap between your office fee for a procedure and the fee the plan allows you to collect for it. No invoice arrives and no check goes out. Your practice-management software files it under "adjustments," and everyone learns to scroll past it. Across a practice, the write-off runs 30–50% of gross production — the range we use throughout Profit Smiles — and it is the biggest single leak in a practice, one that rarely appears anywhere as a number.
It is also getting worse in real terms. Since January 2021, the all-payer reimbursement index the ADA Health Policy Institute tracks has risen 19% while inflation has run 27%; dental supplies and staff wages are each up 23% over the same period. Every year the fee schedule stands still, the write-off quietly grows.
Why "should I drop my PPOs?" is the wrong question
Plans are not equal. Some reimburse fairly. Some lose you money every time a patient sits in the chair. From the schedule they look identical — a patient, an appointment, a claim — and that is exactly why the decision gets made on feel.
The useful question is narrower: for this plan, what do I actually collect for the work I do, and what would happen if I stopped participating? Ask it plan by plan and the answers separate. A few plans turn out to be fair payers worth keeping without a second thought. A few turn out to be the reason the practice works harder every year for the same take-home. The rest sit in between, and the numbers tell you which way they lean.
Framed that way, dropping a PPO stops being one dramatic decision and becomes a series of small, specific ones — most of which are "keep."
Three terms, so the arithmetic is honest
The whole comparison rests on three definitions. Get them straight and every number that follows means the same thing for every plan.
The insurance company is the umbrella, not the regional carrier. A patient with Blue Cross Blue Shield of Texas and a patient with Blue Cross Blue Shield of Oklahoma both count under one company. Count patients, families and production at the umbrella level, or the comparison fragments into carriers too small to tell you anything.
The insurance fee is the allowed fee. When you sign an in-network contract, the company sends you a fee schedule: the maximum allowed amount for every procedure code. Those allowed amounts are what your write-offs are calculated from. If you participate with a company, you have its schedule — from its mailings or its provider portal.
Production is the value of the treatment at the allowed fee, whoever pays. If a root canal's allowed fee is $1,000, and the plan pays $700 while the patient pays $300, production is $1,000. The write-off is the difference between what you would have charged and that $1,000 — not the split between insurer and patient.
The ten-minute check on one plan
You can see the truth about your highest-volume plan tonight, with a calculator and its fee schedule.
- Pick your highest-volume PPO.
- Pull your three most-billed procedure codes.
- For each code, write your office fee in one column and the plan's allowed fee in the other.
- Total both columns. The gap between them, as a share of your office-fee total, is that plan's write-off rate on the work you actually do most.
Do the same for a second plan and you will see the uncomfortable part: the rate is different for every plan you take, and a couple of yours are probably losing money on every visit while looking identical on the schedule.
Three codes is a sample, not an audit. It is enough to tell a 20% plan from a 45% one, which is the decision that matters. The full picture — every code, every plan — is what the tool in the next section is for.
From one plan to all of them
Comparing every plan you take needs three things per insurance company, and none of them is exotic:
| What you need | Where it comes from | Why it matters |
|---|---|---|
| Production for the last twelve months | Your practice-management system's production-by-carrier report | The size of the plan in your practice |
| Patients and families on the plan | The same report, or your patient records | What is at stake if you leave |
| The plan's fee schedule for the codes you use most | The carrier's mailings or provider portal | The write-off, code by code |
With those three, each company gets a write-off percentage — per code and overall — and a single profitability score that combines its production, its patient count and its write-off. Sort by that score once, and for the first time your plans are simply ranked, top to bottom, on what they are worth to you.
A word on pacing, because this is where owners give up. Entering fee schedules company by company is the slowest part of the whole exercise. Done in twenty-minute sittings — four or five companies at a time, one fee schedule per sitting — it typically takes four to nine weeks. That is not a warning; it is the design. The picture sharpens with every company you finish, and nothing is decided until you decide it.
Want this done for every plan you take, from your own fee schedules? The 100 Day Profit Reset Protocol is free for your first hundred days — every tool, no credit card, nothing to cancel.
What leaving would actually cost: the break-even
Here is the calculation that turns fear into a number. Suppose a plan pays you 65% of your office fee, on average, for the work its patients need. Every patient who stays with you after you leave the network pays your office fee instead — 100 cents on the dollar rather than 65. So you could lose 35% of that plan's patients and still collect exactly what all of them produced at the plan's fees.
That is the break-even: the share of a plan's patients you can afford to lose is one minus the plan's fee as a share of your office fee. Four hundred patients on a plan at 65% means 140 could leave and the remaining 260, paying your office fee, would produce what the whole group produced before.
Two things make the real break-even a little more forgiving than that. Leaving a network also ends the insurance-related administrative work that plan generates — the claims, the phone calls, the follow-ups — which PPO Inspector estimates at about $13 per patient per year. And the chairs those patients occupied do not stay empty; they become capacity. The arithmetic above counts neither, which is the right way to run a break-even: before the upside, not after it.
Run it plan by plan first, then across the practice: what happens to production and net impact if you leave the bottom slice of plans by profitability score, keeping a realistic share of their patients? Try the bottom 2%. Then the bottom 10%. Watch how the numbers move. This is the safest way there is to explore the scariest question in dentistry, because nothing has been signed or canceled yet.
Negotiate, drop, or keep
Ranked plans and a break-even on each turn "should I drop my PPOs?" into three ordinary decisions.
Negotiate. A plan with a brutal write-off rate that you would rather keep is a plan to call, now that you can show, code by code, what it costs you. Some carriers will negotiate once the numbers are on the table; the ones that will not have told you something too.
Drop. A plan at the bottom of the list — high write-off, modest production, a break-even that says you could lose most of its patients and be no worse off — is the plan to leave first.
Keep. A plan with a high write-off but a large share of your production may be one to keep, at least for now. The break-even will say so: when a plan carries a big slice of your patients, the number you can afford to lose is still large in absolute terms, and the number you would actually lose is unknown. Keeping it deliberately, with the number in front of you, is a different decision from keeping it out of fear.
Then there is the fourth choice, and it is usually the right first move: leave only the least profitable slice, watch what happens for a few months, and continue from what you learn. Changes of this kind are best phased over nine to twelve months, not made in a week.
Out of network is not "we don't take your insurance"
This is the distinction that removes most of the fear, and it is worth stating plainly because patients, staff and owners all get it wrong.
Dropping a PPO ends the network contract — the participation agreement that binds you to the plan's fee schedule. It does not end the treating of that plan's patients. Out of network, you still welcome them and still file their claims. The plan pays its out-of-network benefit, the patient pays the balance up to your office fee, and no contract forces a write-off. Their benefits are less complete than they were in network; your collections are whole.
So a practice can be out of network with most of its plans and still, truthfully, tell patients it accepts all major PPO insurance. Both are true at once. What changes is not who walks through the door but what you collect when they do — which is why the break-even above is measured in production, not in patients.
How one practice did it
Dr. Prachi Deore runs Coppell Smiles, a solo practice in Coppell, Texas, and hers was the first practice on Profit Smiles — the tools were proven there before they were offered to anyone else.
For years she treated write-offs as weather: something that happens to every practice, nothing to be done about it. What changed her mind was the realization that the plans were not equal. So she put every plan through the same math — what it actually reimbursed, what she wrote off, whether an hour of chair time on that plan made money or lost it — and then, before touching anything, checked what would happen if she dropped each one.
She did not go out of network across the board. The fair payers stayed, and one large plan stayed deliberately because it carried a big share of her patients and the numbers said keep it for now. She left the plans that lost money, in the count of contracts, about 80% of them, and she left them in stages rather than all at once.
Six months after dropping the unprofitable plans, her practice's monthly production was up $20,000.
As she puts it in the protocol's own training: score first, scenario second, decision third.
The order of operations
If you take one thing from this guide, take the sequence, because the sequence is what keeps the decision calm.
- Score. Rank every plan on production, patients and write-off. Finish the fee schedules in twenty-minute sittings; the ranking is only as honest as the schedules behind it.
- Scenario. Run the break-even on your worst-scored plan first, then on the bottom slice of the practice. Be pessimistic about retention, then optimistic, and see whether the decision changes.
- Decision. Negotiate the plans worth keeping, leave the worst slice first, keep the big ones deliberately, and phase the changes over nine to twelve months.
- Repeat. Keep the fee schedules current as carriers update them, and re-run the scenarios whenever a renewal or a fee cut lands on your desk.
Run your own numbers
Two free calculators on this site do the arithmetic from this guide. The PPO write-off calculator turns your collections, your insured share and your average write-off into dollars written off per year and per day, and models what a fee cut from a plan would cost your net income. The out-of-network break-even calculator turns a plan's patient count and its fee as a share of your office fee into the number of patients you could lose and still collect the same production. Both open with an example practice's figures; replace them with yours, and nothing you enter leaves your browser.
For every plan you take, at every code, PPO Inspector runs the same math from your own fee schedules, ranks the plans, and runs the what-ifs — per plan and across the practice — so the decision to negotiate, drop or keep is made with your numbers in front of you.
Sources
- ADA Health Policy Institute, Economic Outlook and Emerging Issues in Dentistry poll, Q4 2025 — reported in Morrissey & Vujicic, "Low Reimbursement Rates Top Dentists' Challenges in 2026," The LEAD, January 18, 2026: 55% of dentists named low reimbursement among their top three challenges for 2026; 35% said they were likely to drop participation in certain networks.
- ADA Health Policy Institute, The State of the U.S. Dental Economy, 2nd Quarter 2026 Update: 23.5% of owner-dentists reported having dropped out of some insurance networks since the beginning of 2026; the all-payer reimbursement index up 19% since January 2021 against 27% inflation; dental equipment and supplies and dental-staff hourly earnings each up 23%.
- Write-offs of 30–50% of gross production is the range Profit Smiles uses across all of its materials. The $13-per-patient-per-year administrative estimate is PPO Inspector's own assumption for the what-if calculations. Dr. Prachi Deore's results are those of one practice, measured in the platform; individual results vary.