• Ambitious enough? $5M+ DSO net across 260 practices is transformational for a single product line
• Specific enough? Provider split %, margin floor, revenue target, timeline for insurance adoption
• Believable? $120 UCR with $28 cost = 76.7% margin (hygienist). Math works if placement shifts.
• Inspires? Doesn't prescribe a single billing strategy; opens multiple pathways

Curodont is a $92 net margin product when placed by a hygienist (3-5 min added chair time, $18-31/min revenue). When a doctor places it, the 30% commission drops net to $56, and it consumes 8-12 minutes of chair time worth $400-600/hour in restorative production. The pricing debate is a symptom — the real problem is who holds the applicator.

• Heartland Dental: Formal vVardis partnership. 125,323+ teeth treated. Uses VideaAI for caries detection + Curodont for treatment. 1,200+ practices, 34 states.
• Aspen Dental: Per Brittney's contact, billing to insurance, 90-100% UCR enterprise-wide. Treating like any other code.
• Peak Dental (CO): Collect upfront, submit to insurance, take the hit on UCCI. Practical, proven model.
• vVardis market data: $85M total funding (OrbiMed). ~10% of US dental offices now offer Curodont. 1M+ teeth treated nationally since Jan 2024. 400K+ patients.
• Material cost (open market): $35-38/applicator retail. SGA's $28 (via procurement negotiation) is significantly below market — this is a competitive advantage.

• CDT 2017: D4346 added. Initially treated by most payers as D1110 (prophy) equivalent.
• 12-24 months: Before most commercial payers formally added D4346 to fee schedules.
• Now (2026): Most plans cover, often at 1.5-2x prophy rate. Delta Dental OR: $80 (vs. $60-80 for prophy).
• Revenue impact: Practices not billing D4346 for qualifying patients lose $150-200+ per patient.
• Key lesson: Practices that submitted claims from day one drove payer adoption faster. Those that waited lost years of revenue and payer data.
• D2991 projection: Expect similar 12-24 month window. SGA is 16 months into that window (CDT effective Jan 2024). Commercial coverage likely by mid-2026 to early 2027 for major payers.

• "Patient needs 13 sites. They refused treatment because it's too much money." — At $120/tooth, that's $1,560.
• "At this price our office will stop doing this procedure. Only two of us are doing it right now."
• "I asked my OM to call all insurances... She said nobody has time. RCM told her they won't do it either."
• "We haven't sent any off to insurance yet. Comparing it to SDF rates, they could be really low."
• Heritage comparison: charges $44/surface, treats adjacent teeth for free with one applicator.

• "I have been told RCM will NOT allow us to change curodont fees. Therefore Peak will NOT be doing any curodont."
• "In 35 years of doing this I have many times come across what the company says and it does not align with reality."
• "I personally am not 100% convinced in this product... being mandated on there is no wiggle room has me feeling like I am being told what treatment to give my patients."
• Biochem objection on 1:1 ratio — no specifics provided despite being asked.
• Delta AZ: doesn't recognize as covered → "we can charge what we want."

• "We are going to hold off at Topeka Dentistry for a harder push until we have an idea on the math of reimbursement."
• Had her insurance coordinator call payers directly: Delta KS $35, UCCI TDP $4.42, UCCI Advit $4.61.
• "We are running out of 'grace' to implement things with our team only to have it be bumpy, messy, and back pedal at the end."
• Did NOT ask about balance billing — the critical missing question.

• "My concern is the 1:1 ratio. Which equates to one site and not 'up to 3 teeth' that can be treated?"
• Teams were trained on V1 applicator — V2 has different 1:1 protocol.
• Refresher not on her calendar, hygiene team unaware.
• This is exactly the training gap May 5th needs to fix.

References HITECH Act (42 U.S.C. § 17935). Patient acknowledges:

• They ARE covered by a dental insurance plan
• They do NOT want the office to submit the claim to insurance
• They understand they'll pay the full amount out-of-pocket
• Payments will NOT count toward their deductible
• They have "freely chosen" to self-pay after considering options

• Contradicts D4346 lesson: The form instructs the practice NOT to submit to insurance. But building claims volume is exactly how you drive payer adoption.
• Patient perception: Brittney: "it might feel slimy." Asking patients to waive insurance triggers suspicion.
• PPO contract risk: Many PPO contracts require submission of claims for services rendered. Actively NOT submitting could be a contract violation.
• Unnecessary if collecting upfront: You can collect full fee AND submit to insurance. No form needed to do that — just inform the patient their insurance may not cover it.
• Recommendation: Do NOT use this form. Use a simple, one-paragraph acknowledgment that says "insurance coverage is uncertain, you're paying today, we'll refund if insurance covers it."

1,000+ locations. Billing D2991 to insurance. Seeing 90-100% UCR. Charging ~$120/tooth. Treating it like any other code.

1,200+ practices. 80-90% UCR enterprise-wide. Some payers "not playing nice" but not earth-shattering. Formal vVardis partnership with 125K+ teeth treated.

Colorado DSO. Collect upfront, submit to insurance, refund if paid. UCCI pays $4 — "we take the hit." This is the model SGA should follow.

• Step 1: Place Curodont, enter D2991 into DPMS with standard UCR ($120)
• Step 2: Submit claim to insurance with diagnosis code K02.61 (arrested dental caries)
• Step 3: Insurance pays or denies. If denied, patient responsibility per normal collections
• Step 4: Balance bill where PPO contract allows. Write off where it doesn't.
• Sliding scale: Custom suffix codes in DPMS (D2991.1 = $120, D2991.2 = $105/ea, D2991.3 = $95/ea, D2991.4 = $85/ea, D2991.5 = $75/ea). Suffixes stripped on claims — standard DPMS behavior per Open Dental/Dentrix/Eaglesoft documentation.

D4346 (gingivitis scaling) in 2017. When this code launched, practices that treated it like any other code and kept submitting claims drove payer adoption faster than those who avoided billing. Volume of claims forces payer recognition. Same playbook that Aspen and Heartland are running.

• Zero process overhead — nothing new for front desk or RCM to learn
• No compliance risk from special forms
• Builds claims volume that drives payer adoption (D4346 lesson)
• Consistent with how Aspen and Heartland operate
• Doctors stop feeling like this is "different"

• Cash flow risk — RCM must chase payments on denied claims
• RCM says their team is too small for the volume
• Unknown balance billing rights for many payers
• May need to write off UCCI cases entirely ($4 + $28 cost = $24 loss per treatment)
• Doctors frustrated by uncertainty may slow adoption

• Compliance: Low (standard billing)
• Cash flow: Medium-High (delayed collections)
• Complexity: Very Low
• Doctor buy-in: High (familiar process)
• DSO margin at risk: 15-25% of treatments during adoption window

• Step 1: Patient signs consent acknowledging insurance may not cover D2991, agrees to pay full fee upfront
• Step 2: Collect $120 (or sliding scale amount) at chair
• Step 3: Submit D2991 claim to insurance with K02.61 narrative
• Step 4: If insurance reimburses, refund patient the insurance portion
• Form options: Mitch's "Election to Self-Pay" form from legal, OR a simpler "Insurance May Not Cover" acknowledgment (not a waiver from billing)
• Sliding scale: Same quantity tiers. D2991.1=$120, D2991.2=$105/ea, D2991.3=$95/ea, D2991.4=$85/ea, D2991.5=$75/ea

Peak Dental Services (Colorado). This is exactly what Peak runs for Curodont. They told Brittney directly: "It makes more sense to have them pay upfront and then let them know insurance will pay or it won't. We'll reimburse if it does. That way you're not chasing money, you're refunding money." This is also similar to how elective medical procedures (LASIK, cosmetic) handle insurance uncertainty.

• Cash flow protected — money in hand before claim processes
• RCM workload reduced (refunding is easier than chasing)
• Still builds claims volume for payer adoption
• Patient gets a pleasant surprise if insurance pays
• Peak Dental validates this works in the real world

• Extra form = extra step at chairside (doctor frustration point)
• Patient may hesitate signing — Brittney: "it might feel slimy"
• Refund process adds admin work (though less than collections)
• Different from every other procedure — "why is this one special?"
• Compliance question: does "election to self-pay" create balance billing exposure?

• Compliance: Medium (form language matters)
• Cash flow: Very Low (collected upfront)
• Complexity: Medium (form + refund workflow)
• Doctor buy-in: Medium (extra step frustrates some)
• DSO margin at risk: <5% (only UCCI-type outliers)

• Tier 1 — Pays Well (≥80% UCR): Submit claim normally. Collect copay at chair. Standard dental billing. (Target: most major payers within 12-18 months)
• Tier 2 — Pays Poorly (20-79% UCR): Collect upfront, submit claim, refund insurance portion. Balance bill where contractually allowed.
• Tier 3 — Doesn't Recognize / Hostile: Collect full fee upfront. Still submit claim to build volume. No expectation of payment. (UCCI lives here)
• Implementation: Build a payer lookup table in the DPMS or a shared spreadsheet. Front desk checks insurance before appointment, knows which workflow to follow.
• Sliding scale: Same across all tiers. Payer tier affects billing workflow, not patient pricing.

Pharmacy Benefit Manager (PBM) routing. When pharmacies dispense medications, the system automatically checks the patient's PBM, knows the copay tier, and routes the transaction accordingly. Some drugs are covered, some need prior auth, some are cash-pay. The pharmacist doesn't decide — the system routes. Same principle: don't make front desk guess, give them a lookup.

• Optimizes revenue per payer — never leaves money on the table
• Adapts as payers add D2991 to fee schedules (just move them to Tier 1)
• Front desk gets clear instructions per patient
• Can be automated into SGA platform eventually
• Best long-term architecture as payer landscape evolves

• Requires building and maintaining payer database across 260 practices
• Different DPMS systems complicate lookup (Brittney flagged this)
• Training burden — 3 workflows instead of 1
• Initial data collection is manual and incomplete (RCM couldn't even answer basic questions)
• Overkill for current scale of Curodont placements

• Compliance: Low (each tier is compliant on its own)
• Cash flow: Low (protected in Tier 2/3)
• Complexity: High (multi-workflow, payer DB)
• Doctor buy-in: Medium (smart but they don't want complexity)
• DSO margin at risk: <10% (optimized per payer)

• Colorado (SB17-190): Dental plans cannot dictate fees for non-covered services. If a payer doesn't cover D2991, the practice CAN charge full UCR. This is not balance billing.
• Arizona (per Dr. Shanahan): Delta Dental AZ doesn't recognize D2991 as covered. "We can charge what we want."
• 44 states have similar protections per Monday's legal analysis
• Catch: You must still submit the claim. The non-covered classification is the payer's decision, not the practice's. The "non-covered services acknowledgment form" doesn't give permission to skip billing.
• Sliding scale: Same quantity tiers. Patient always pays the practice price. Insurance is irrelevant in non-covered states.

Cosmetic dermatology. Botox for cosmetic purposes is never submitted to insurance. The provider charges their fee, patient pays, done. But when the same Botox is used for migraines (medical necessity), it goes through insurance. The same product has two billing pathways depending on classification. Curodont could follow this — where payers classify it as non-covered, it's a cash service; where they recognize it, it's a billable procedure.

• Maximum revenue protection in non-covered states
• No insurance games — clean cash transaction
• Dr. Shanahan already operates this way in AZ
• Colorado law explicitly supports this model
• Zero RCM overhead for non-covered payers

• Must still submit claims — can't just skip billing even with non-covered classification
• Fails the D4346 lesson: not submitting claims delays payer adoption
• State-by-state legal variation creates compliance patchwork
• SGA operates in multiple states — can't have one universal policy
• Brittney explicitly rejected the original non-covered form approach

• Compliance: Medium-High (state law research required per state)
• Cash flow: Very Low (full collection)
• Complexity: High (multi-state compliance)
• Doctor buy-in: Mixed (AZ doctors love it, others uncertain)
• DSO margin at risk: <5% but slows industry-wide payer adoption

• Step 1 — Sliding scale in DPMS: Custom suffix codes per Brittney's pricing strategy. D2991.1 (1 tooth=$120), D2991.2 (2=$105/ea), D2991.3 (3=$95/ea), D2991.4 (4=$85/ea), D2991.5 (5+=$75/ea). Suffixes stripped on 837D claims — confirmed by Open Dental, Dentrix, and Eaglesoft documentation. Each suffix has its own fee in the fee schedule.
• Step 2 — Collect at chair: Patient informed insurance may not cover. Full sliding-scale amount collected at time of service. Use a simple, one-paragraph acknowledgment (NOT the complex "election to self-pay" form).
• Step 3 — Always submit D2991: Every single placement gets billed to insurance with K02.61 narrative. This builds the claims volume that forces payer adoption. No exceptions.
• Step 4 — Refund when insurance pays: If payer reimburses, refund patient the insurance portion. Pleasant surprise for patient, builds loyalty.
• Step 5 — Passive payer intelligence: Track every EOB result in a shared spreadsheet or database. Over 3-6 months, SGA will have the most complete D2991 payer database in the DSO industry. This becomes the data that feeds Solution 3's smart routing later.
• Step 6 — UCCI exception: For known hostile payers (UCCI at $4), flag in morning huddle. Doctor/hygienist makes clinical decision knowing margin is thin. Don't stop treatment — the clinical value is real — but practice is informed.

• From Solution 1: Always submit claims (D4346 lesson, Aspen/Heartland validated)
• From Solution 2: Collect upfront (Peak Dental validated, protects cash flow)
• From Solution 3: Build payer database passively (smart routing comes later when data is mature)
• From Solution 4: In states where D2991 is non-covered, full UCR collection is legally protected anyway
• Addresses Brittney's concern: No complex forms. Simple acknowledgment. Treat like a new code with one reasonable protection (upfront collection).
• Addresses doctor frustration: Sliding scale gives them the pricing flexibility they demanded. Quantity-based, not DOT codes.
• Addresses RCM capacity: They refund, not chase. The hard work is done at chairside.

• Cash flow protected from day one
• Claims volume drives payer adoption (long game)
• Sliding scale satisfies doctor demands
• Simple acknowledgment, not a complex legal form
• Builds proprietary payer intelligence database
• Consistent with external benchmarks (Aspen, Heartland, Peak)
• Evolves naturally into smart routing (Solution 3) as data matures

• Still requires upfront collection (one extra step vs. Solution 1)
• Refund processing adds some admin overhead
• UCCI cases still lose money ($4 reimbursement vs. $28 cost)
• Payer database requires someone to maintain the spreadsheet
• Need legal review of acknowledgment language per state

• Compliance: Low-Medium (simple form, always submit claims)
• Cash flow: Very Low (collected upfront)
• Complexity: Low-Medium (one workflow, one form)
• Doctor buy-in: High (sliding scale + familiar billing)
• DSO margin at risk: <8% (UCCI outliers only)

• D2991.1 = 1 tooth @ $120 | D2991.2 = 2 teeth @ $105/ea | D2991.3 = 3 teeth @ $95/ea | D2991.4 = 4 teeth @ $85/ea | D2991.5 = 5+ teeth @ $75/ea
• Suffixes are stripped on 837D claims — this is by design. Only D2991 reaches the payer. The suffix manages internal pricing, reporting, and auditing.
• Works in all 3 DPMS: Open Dental (truncates to 5 chars), Dentrix (alias codes), Eaglesoft (service code → ADA code mapping)
• Why this beats manual fee override: Self-documenting, auditable across 260 practices, trainable ("how many teeth? pick the matching code"), consistent.
• Per-tooth claim lines: Each tooth is a separate claim line with tooth number. 3 teeth = 3 lines of D2991, each with the D2991.3 internal fee ($95).

• Material cost per treatment: $28.00 ($279.99 / 10)
• Hygienist floor (cost only): $28 — any fee above this is margin
• Doctor floor (cost + 30% commission): $40 fee = $0 DSO net. $55 = $10.50 net.
• Brittney's recommended doctor floor: $55
• Brittney's recommended hygienist floor: $40
• Proposed sliding scale floor ($75): Covers both provider types with margin to spare

• Sliding scale replaces flat $120: 5 suffix codes in the DPMS fee schedule. One-time setup.
• New acknowledgment form: One paragraph. Replaces the Election to Self-Pay form AND the old non-covered services form.
• Always submit to insurance: Some practices weren't submitting. Now every placement gets a claim. No exceptions.
• Refund workflow: If insurance pays, refund the patient. This is new but simple.

• $120 UCR (1 tooth): No change to the base price.
• Doctor 30% commission: No change to compensation structure.
• Hygienist-first placement: Continue driving toward hygiene chair.
• Morning huddle identification: Already happening.
• Clinical workflow: Same V2 applicator protocol. May 5th refresher addresses training gaps.