What exactly is a PPO and HMO...sorry for the newbie question.
PPO = Preferred Provider Organization. This is an insurance plan where if you choose to particpate with the plan(lets say with Delta Dental for arguement sake) you will be listed as a preferred provider in a list that is given to all enrollee's whose employer has chosen that Delta Dental Plan. Employees who have this PPO plan can choose any dentist enrolled as a PPO provider and receive the PPO benefits. The plan will have you accepting a fee schedule determined by the insurance company that theoretically is set based on the fees of other dentists within your immediate geographic area(generally within a couple of zipcodes of where your office is). This PPO fee schedule will often be set as a percentage of what is called the UCR fees(Usual, Customary and Reasonable). Most decent PPO's will have UCR fees at the 90% level for an area, meaning that the fee the insurance company pays out is at the 90th percentile of fees in that area. If you're enrolled in that PPO, the contract that the insurance company has with you says that for them listing you as a preferred provider and theoretically steering the patients enrolled with them towards your office, the maximum you can charge those enrolled patients is the UCR set by the insurance company and you can't bill the patient the difference(if any). For example, Lets say you're a Delta Dental PPO enrolled dentist and your fee for a 1 surface amalgam filling is $110, but Delta's UCR fee for that filling is $100. If a Delta Dental enrolled patient comes to your office and you do that 1 surface amalgam on them, you can only charge them the $100 and you write off the extra $10. What then happens since most insurance plans will cover 80% of the UCR for restorative fees, is that Delta will actually pay out $80 for that filling, and then you can bill the difference upto the UCR fee. So in this case, you end up charging $110, writing off $10, receiving $80 from Delta Dental and $20 from the patient. Yes, its confusing at times, especially since the percent of a fee covered varies depending on the plan (generally preventative is 100%, restorative is 80% and endo+crown and bridge is 50%), and the patient has a yearly maximum($1000 - $2000 is the normal range), which if you then go over that amount, you can bill the patient for the entire procedure upto the UCR. These PPO plans tend to be liked by patients and dentists. Some proceedures that you may do may not be a covered procedure, where the patient is responsible for that fee, and sometimes the insurance company will either downcode(i.e. you do a posterior composite, but the insurance company will only reimburse upto the amalgam fee for the same sized filling and the patient is responsible for the difference upto the UCR fee) or bundle codes (i.e. a patient comes in for a cleaning, bitewings and a periodic exam, 3 seperate billing codes, but the insurance company will bundle it together into an "adult recall" as 1 code at usually a couple of dollars less than the 3 individual codes would be)
HMO (Health Maintenance Organization) or for the dental side is sometimes called a DMO (dental Maintenance Organization). These aren't well liked by dentists generally, but employers tend to like them because they cost them less than a PPO. How a HMO/DMO works is that if you choose to enroll in one as a dentist, the insurance company will again list you as a HMO/DMO provider. For the companies that choose this insurance option for their employees, if they choose you as a their dentist, they have to enroll notify the insurance company that you will be their dentist. The insurance company will then pay you a flat fee monthly for you to provide what ever care that enrolled person needs. If they just need a cleaning twice a year, you'll make money off the deal, if they need alot of work, you'll loose money on that patient. Basically for most HMO's/DMO's to be financially attractive to you as a dentist, you need to have ALOT of patients enrolled with you, and hope that they either don't come in to see you regularly, or if they do that they don't need alot of work. Insurance companies will advertise this plan to dentists as a way to "fill empty chair time". Most dentists don't like this and hence don't enroll in one of them as a provider.
The third major type of insurance plan out there is the FFS or Fee For Service. This is where insurance plans originated. Basically, a person enrolled in a fee for service plan can see who ever they want as a dentist, often reguardless of whether that dentist is enrolled as a provder with that insurance company, and then the insurance company will reimburse at the dentist's full fee upto a yearly maximum. As a dentist, you tend to really like these few and far between plans.
After you've seen a few of them firsthand, it gets alot easier to comprehend. Often, you'll pcik and choose what plans (if any) you decide to enroll with based on what the major businesses in your area use for dental insurance plans and what the offered fee schedules are. One other little caveat that many insurance companies will include in their contracts with you is a clause that basically states that within a type of plan(FFS, PPO, HMO/DMO) if you're enrolled with similar plans from other insurance companies, the fee that they pay you will not be above the lowest fee you accept(i.e. back to that 1 surface amalgam, if your fee is $110, and your enrolled as a PPO with Delta Delta and Aetna, if Delta's UCR for that is $100 and Aetna's is $95, Delta will only reimburse upto the $95 and once again you can't bill the difference)
Bottom line, choose your plans wisely, and don't hesitate to use the resources of the contract laywers that the ADA has on staff to review and advise you of the many, many insurance plans you'll be offered to enroll in.
And that doesn't even take into account our doctors exam fee that goes along with those previously mentioned billing fees. Multiply that by a couple hygenists, and then 8+ patients per day per hygenist over the course of a year and it adds up.
