Dental Practice Types [FFS/HMO or DMO/PPO]

[DrTacoElf]

Hey guys i want to start a discussion on practice types. Here is my current level of understanding.


FFS - You set your rates, and the patient usually has insurance coverage that will pay an ammount for each procedure that is usual and customary for your area. You file for an insurance claim and the patient pays the difference between your fee and what insurance is willing to pay. Also these types of insurance plans typically have yearly caps $1000 - $2000.

Question: What is preauthorized treatment? Is it something along the lines of if you perform a procedure charge X ammount, patient pays the difference between your fee schedule and insurance payment (which you are Anticipating in the mail) and insurance company denies the claim?

HMO/DMO - you sign up and take patients each for a set ammount (i.e $5 per patient) each month you get a "capitation" check whether or not you do anything for these patients. common complaints include the use of poor supplies b/c as a business owner you can't be in the red!

PPO - Can be used for FFS sometimes, but only will cover UCF for non-network dentists and patient must pay the difference. If you are a PPO doctor you will agree to perform a particular service at a reduced rate to generate patient pools. My dentist advised against ever doing this (even in the beginning) b/c it hurts dentistry. (not quite sure what he meant exactly, but i'm guessing its along the same principal as OPEC about 5 years ago (price wars).



Last question: idealy everyone would be FFS and charge whatever they wanted to and economics would set prices. However that is not the case. What do you guys think about HMO/DMO PPO? Evil or acceptable. What about denying HMO patients (are you not preventing them from getting care?)
that is my biggest question.

Thanks!

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[aileen]

Many insurance companies want you to submit and get pre-authorization before you do any major work (crowns, bridges, dentures, etc). Pre-authorizations are not guarantees of payment, but they reduce your chance of not getting paid by insurance companies. The insurance dentists will review the x-rays and documents and decide if the patient indeed needs the treatment or not. That sucks, but that's how it works...

About HMO/DMO... Say you have a HMO patient who need upper and lower dentures. You get paid $10 a month from the insurance. You make the dentures for the patient, and for some reason, the patient doesn't want you any more and change the doctor starting next month. You only got paid 3 months worth of capitation money. How's that?

 

[DrTacoElf]

Woah that sucks. Well basically here is what i want to know. If you get the question would you accept HMO/DMO at an interview what should you say. From a business standpoint it sure sucks. But by refusing to sign up for it are you DENYING care to anyone? Any thoughts on this...

 

[content]

Hey, don't forget about direct reimbursement. Patient pays for entire bill and is then reimbursed by employer/dental insurance company for portion of bill that was covered. This is the form of payment the ADA is currently pushing.

 

[aileen]

I wouldn't worry too much about patients not getting any dental care. There will always be some dentists who would take HMO/DMO. The whole world is not your responsibility. Sad (and harsh) but true...

I doubt anyone would ask you if you're willing to accept DMO at your interview. How many predents would know how dental insurance works? I'm NOT looking down on anybody. It's just not our job to know about those stuff yet. They probably just ask how you would feel about HMO. I would say that HMO is one of the biggest obstacles in providing quality dental care to the public.