Unlock the PPO

Cigna announced a new shared network agreement with Guardian effective 8/1/26 . . . does this impact your office?

Video Created with Dubb on Jun, 2 2026

If you will be at the South Dakota Dental Association Convention, please visit Sandi as she's speaking during the Friday morning session on PPO Insurance Control, Negotiations and Strategy!

CE Speakers, Courses, Handouts

There have been so many new agreements added between insurance companies and third parties that it's become difficult to know what fee schedule applies when. Hopefully this helps sift through some of the confusion:

DOES A DIRECT CONTRACT ALWAYS TAKE PRIORITY OVER A SHARED NETWORK AGREEMENT?
No. With most companies, it does but there are a few exceptions. In general, when you sign a direct contract between you and the insurance company, those fees will override any shared network agreements but not always. Two more notable exceptions are United Concordia and Ameritas which may downgrade to a lower paying option even when you have a direct contract in place. You can typically opt out of lower agreements to push the fees back to the direct contract rates.

IF I HAVE A CONTRACT AND RECEIVE A NOTICE THAT THEY ARE ENTERING INTO A NEW SHARED NETWORK AGREEMENT WITH ANOTHER COMPANY, HOW DO I KNOW IF I'M BEING INCLUDED?If
You will automatically be added into any new shared network agreement by default. You can typically opt out of new agreements but the burden is on you to opt out. And after you send an opt out, be sure to follow up. We see a surprisingly high number of opt outs that need follow up confirmation to get them in place.

I'VE NOTICED THAT I'M GETTING SOME PATIENTS WITH AN INSURANCE COMPANY UNDER ONE FEE SCHEDULE AND OTHER PATIENTS WITH THAT SAME COMPANY ANOTHER ANOTHER FEE SCHEDULE. HOW IS THAT POSSIBLE?
While not common (and be sure that the insurance company didn't just make a mistake first), it can happen. An example of this would be an office that has a United Healthcare direct contract but has opted out of Medicare. If they have another shared network contract that also picks up UHC Medicare, that shared network agreement may be picking up just the UHC Medicare portion while the commercial plans remain with the direct contract.

WHY AM I NOT BEING PICKED UP WITH A SHARED NETWORK AGREEMENT BUT SOMEONE ELSE I KNOW IS?
There can be lots of reasons. Shared network agreements change over time. For example, in September, 2022 Aetna decided to no longer pick up under Zelis with new additions however if an office was already getting Aetna via Zelis prior to that, they were allowed to remain with Zelis. An office down the road may be getting Aetna in-network via that relationship but if you are trying to add it now, you would not get added through this path. In some cases, a brand new pickup may occur but if you drop a direct contract, that pickup may take longer through a shared network or there may be a block in certain cases. There are some relationships that are active in some states but not all so someone in a different state may have access to a relationship you do not or vice versa. It may also be a case where someone was picked up when providers were needed in the area and that is no longer the case. This is why we recommend caution in knowing that advice given about someone's situation may not apply unilaterally and knowing exceptions is important.

WHAT IF I'M NOT SURE IF I'M IN-NETWORK THROUGH A DIRECT CONTRACT OR A SHARED NETWORK AGREEMENT, HOW DO I FIND OUT?
You can always call the insurance company and ask if you are showing up in-network and, if so, what fee schedule they are showing you attached to in their system. The other way is to check an EOB, the relationship should be noted and you can cross check the fees to the fee schedule listed. It's good office protocol now to spot check EOBs every few months regardless since it's hard to catch when companies may be downgrading without cross checking.

Join Sandi's latest podcast with our friends at ACT for PPO tips to kick of your year right!

Podcast | ACT Dental ACTdental Podcast - The Best Practice Show with Kirk Behrendt