Dental insurance may be included as part of an employer’s benefits package or purchased separately; typically it features monthly premiums, deductibles, and annual maximums.
Experts advise adults to visit the dentist at least twice each year, with most plans accommodating this recommendation by covering preventive visits and some services such as X-rays, fillings on multiple teeth at once, crowns or bridges. However, some policies have restrictions or time limitations when it comes to other services like crowns and bridges.
PPOs
Preferred Provider Organization (PPO) dental plans allow insurance providers to contract with a network of dentists who agree to offer lower, negotiated rates for services, which allows patients to select in-network providers but also covers out-of-network ones.
PPO plans differ from HMOs in that they don’t typically require you to visit one primary care dentist; you can go directly to any specialist without referral from that primary dentist. However, these plans typically have deductibles and annual maximums before paying will start from your insurance company.
Many PPOs allow offices to utilize third-party administrators for claims processing, which could potentially save your office money on claims-handling costs. It’s important to understand how these services could impact patient fees.
HMOs
HMOs are a type of managed care dental plan. These plans feature provider networks and patients are incentivized to visit dentists within that network; out-of-network visits typically are covered only under special circumstances; reimbursement will likely follow an “allowances table,” significantly decreasing benefits.
Most HMOs require that patients select a primary care dentist and obtain referrals from him/her for specialist visits, which can limit choice and flexibility. On the plus side, many HMO plans don’t have annual deductibles to worry about meeting; this can help those on tight budgets. Furthermore, many offer fixed copayments across services which provides predictability in out-of-pocket costs; they may even waive claim forms altogether!
Indemnity
While indemnity plans may be more costly than PPO or HMO plans, they can be an economical option for those who prefer keeping their own dentist. They reimburse dentists based on what the insurance company deems reasonable fees.
Professional Indemnity insurance protects dentists against damages from third-party claims stemming from their professional duties, as well as costs incurred defending such claims and any legal expenses related to it.
Indemnity plans usually contain both a deductible and annual maximum, so those opting for them should make sure it provides them with enough coverage as well as consider any associated costs of fulfilling their deductible before making their decision. A good dental agent may help ensure they make an informed decision.
Table or Schedule of Allowance
Many indemnity plans utilize an Uninsured Claims Repayment Fee Schedule that specifies what they believe each procedure should cost and then uses this figure as the basis for benefits paid out on dental claims.
These fees vary based on your insurance carrier and dentist, respectively. Furthermore, costs could differ according to geographic region or specific services rendered.
Some plans require you to meet a deductible before they will begin paying, with most deductibles reset each year and coinsurance percentages adjustable accordingly.
Before your deductible and annual maximums reset, it is vitally important that any outstanding work be taken care of immediately. This will ensure your FSA (pre-tax health savings payroll deductions) dollars are spent efficiently and effectively while helping to minimize unexpected bills that may pop up later on.
Capitation
With capitation or dental health maintenance organization (DHMO) programs, contracted dentists are paid a fixed monthly amount per enrolled patient enrolled into these plans; many also include patient co-payments to offset costs.
Capitation plans are popular among large self-insured groups and may be profitable for some providers; however, solo general dentists who have overhead costs above the national average often find that capitation plans cannot provide enough compensation to meet income objectives.
Contracting with these types of plans requires considering who is responsible for sharing data and information between providers and payers, and understanding attribution rules can impact performance results – this is particularly relevant when products hinge on complete diagnosis code submissions.
