PAYMENT FOR DENTAL

CARE

DR. M. DHIVYA LAKSHMI

MECHANISM FOR PAYMENT OF DENTAL CARE

Private fee for service. Post payment plans. Private third party prepayment plans

A) Commercial insurance companies B) Non profit health service corporations E.g.: Delta dental plans, blue cross /blue shieldC) Prepaid group practice D) Capitation plans Salary Public programs.a) Medicareb) Medicaidc) Veterans Administrationd) National Health Insurance

PRIVATE FEE FOR SERVICE Two party arrangement Traditional method Commonly practisedADVANTAGES: Culturally acceptable Flexible Administratively simpleDISADVANTAGES: Some potential patients who

cannot afford dental care offered.

POST PAYMENT PLANS Introduced in late 1930’s by

local dental dental societies in Pennsylvania & Michigan.

“Budget payment plan”. the patient borrows money

from a bank or some finance company to pay the dentists fee.

After the application is approved by the lending institute the dentist is paid the entire fee. The patient then repays the loan to the bank in budgeted amounts.

PRIVATE THIRD PARTY PREPAYMENT PLANS It is defined as ‘’payment for services by some agency rather

than directly by the beneficiary of those services’’.

1st PARTY - DENTIST 2nd PARTY - PATIENT 3rd PARTY – FINANCE ADMINISTRATOR

REIMBURSEMENT OF DENTISTS IN PREPAYMENT PLANS USUAL, CUSTOMARY & REASONABLE FEE (UCR)USUAL FEE: The fee usually charged for a given service by an individual dentist to private patients – his/her “usual fee”

CUSTOMARY FEE: Fee in the range of the usual fee charged by dentist of similar training & experience for the same service within the specific & limited geographic area.

REASONABLE FEE: If it meets these 2 criteria

TABLE OF ALLOWANCES A table of allowances is

defined as a list of covered services that assigns to each service a sum that represents the total obligation of the plan with respect to payment for such service but that does not necessarily represent a dentist’s full fee for that service.

ADA IS OPPOSED TOCAPITATION:A capitation fee is defined as a fixed monthly or yearly payment paid by a carrier to a dentist in a closed panel, based on the number of patients assigned to the dentist for treatment

FEE SCHEDULES:List of charges established or agreed upon by dentist for specific dental services. Usually taken to mean payment in full.

COMMERCIAL INSURANCE COMPANIES Operate for profit.

ADVANTAGES DISADVANTAGES

COMMERCIAL INSURANCE COMPANIES

Payment is quicker & hassle free.

No fee audits & post treatment dental examination to assess the quality of care delivered.

Do not encourage utilization of services

Charge higher premiums.

NON-PROFIT HEALTH SERVICE CORPORATIONS - DELTA DENTAL PLANS June 1954, the Seattle District Dental Society Comprehensive dental health care program for children upto 14 years. A dental service corporation is legally constituted non- profit organisation

incorporated on a state by state basis and sponsored by a constituent dental society to negotiate an administrator contract for dental care.

• The National Association of Dental Service Plans (NADSP) was formed

in June 1966 with the help from ADA.

• The NADSP changed its name to Delta Dental Plans Association in April

1969.

• The underlying philosophy of the Delta Dental Plans is that the dental

practitioners can adapt their traditional practice to meet the demand for

group purchase of dental care.

Specific approaches to monitor quality care provided and to maintain

program’s costs within limits.

Board of directors – mostly dentists.

Series of post treatment examinations

Examined to ensure – a) care claimed & provided has been provided b) Acceptable quality

Mechanism of cost control – co insurance, pre authorisation procedures for certain treatment and annual limits on specific items of care.

They have an obligation towards community. Encourage utilization of services.

REIMBURSEMENT OF DENTISTS IN DELTA PLANS UCR concept almost exclusively. A PARTICIPATING DENTIST has contractual agreement with

delta plan to render care to covered subscribers. Conditions for participating dentists:Pre filing of usual & customary feeAcceptance of payment at 90th percentile.Fee audits by auditors from deltaPost treatment assessment of randomly chosen patients.NON PARTICIPATING DENTIST: no fee audit, lower percentile, 50th percentile, or median.

PREPAID GROUP PRACTICE ADA (1969) has defined grouped practice as ‘’group practice

is that type of dental practice in which dentists, sometimes in association with members of other health professions agree formally themselves on certain central arrangement designed to provide efficient dental health service’’.

HEALTH MAINTENANCE ORGANIZATION

HMO is defined as a legal entity which provides a prescribed range of services to each individual who has enrolled in the organization in return for prepaid, fixed and uniform payment.

SALARY Dentists in same group practised

those in the armed forces and those employed by public agencies are salaried.

largely free of the business concerns of running a practise

Fringe benefits are also often attractive.

Disadvantages:-

There could be a lack of financial

incentive that some dentists, need

to be highly productive.

MEDICARE Title xviii of the social security

amendments of 1965 is the program known as ‘’Medicare’’. This program removed all financial barriers for hospital and physician services for all persons aged 65 and over, regardless of their financial means.

• 2 parts

• Part A, Hospital Insurance

• Part B, supplemental medical

Insurance. Medicare was brought into being

because the voluntary health insurance system was unable to provide adequately for persons over age 65.

MEDICAID It is the name given to title xix of the social

security amendments of 1965. The original intent of the program was to provide funds to meet the health care needs of all indigent and medically indigent persons.

Basic services ,

• In patient hospital care

• Outpatient hospital care

• Laboratory and x-ray services

• Skilled nursing facility services

• Home health services for individuals aged

21 years and older.

• Early and periodic screening ,diagnosis

and treatment (EPDST) program for

individuals under 21 years

• Family planning services

• Physician services