Some questions about paying for treatment

[Visceral]

I just have a question about the different ways dentists are compensated when out in private practice.

In Canada, the different provinces each release a fee guide that provides the suggested fees for treatment. I assume all the states in the USA work in the same way. Now, not every dentist will be compensated for this full fee depending on what type on insurance the patient may be on etc. I'm just gonna list the different plans I know of and if you guys could just confirm if I have the right idea or correct me. Feel free to add any other systems you know too.

Anyways:

Cash payment directly - Seems ideal since you get the full fee directly from the patient, although not many patients may be able to afford it

Insurance - Is there insurance that goes by the state/provincial fee schedule? Would seem ideal since no cuts to fees. This could come with various deductible or copayments that may make it more or less appealing to patients. The copayment must be collected from the patient, of course, but I hear some dentists do not collect.

This is where I get confused when managed care comes into play...

HMO - I have no idea how this system works. I assume they have their own fee guide which reimburses dentists poorly? I guess dentists can choose to accept it or not, although patients may not be happy. If the insurance company's fee guide would only compensate for 80% of a $75 treament that the state fee guide suggests should cost $100, can the dentist only collect the $15 copayment or go for the $40 from the state fee guide?

PPO - I think for this one dentists sign up with an insurance company that will refer their patient base to you for treatment, but you must accept their lower reimbursement rate. Without signing up you're unlikely to see these patients since they will see another dentists who signed up on the PPO plan.

Anyways, managed care looks like it sucks. I hope you guys can clarify this for me because I am a little bit confused on how dentists are compensated out in private practice. Thanks!

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[doc toothache]

Anyways, managed care looks like it sucks. I hope you guys can clarify this for me because I am a little bit confused on how dentists are compensated out in private practice. Thanks!

Whether or not "managed care sucks" is a function of the role we play either as a patient or as a provider.

 

[Visceral]

Whether or not "managed care sucks" is a function of the role we play either as a patient or as a provider.

Thanks for the response. Is my description of managed care correct? And can you clarify how managed care can be good or bad.

I've seen lots of resistance to PPO programs in my province where dentists unite and refuse to accept them as a whole to deter them from getting a foot in the door.

 

[DrJeff]

Thanks for the response. Is my description of managed care correct? And can you clarify how managed care can be good or bad.

I've seen lots of resistance to PPO programs in my province where dentists unite and refuse to accept them as a whole to deter them from getting a foot in the door.

You kind of need to make a distinction between a FFS (fee for service) and PPO (Preferred Provider) and a HMO/DMO type plan, especially the later 2 because they are definately different and definately have their places if that's how one is comfortable practicing.

In the PPO, if you enroll with that insurance company/companies that are offering one, you agree to accept the fee schedule that they are offering independent of what your "normal" fee is and you can't then bill the difference in most plans (for example, if your usual fee for a 1 surface amalgam was $100, and the PPO you were enrolled in set their UCR (Usual, Customary and Reasonable) fee for that procedure at $90 - you'd be re-imbursed thr $90 and would write off the extra $10. For doing this, you'd be listed as a "Preferred Provider" with that insurance company and folks enrolled with it in your area would see your name and hopefully select you as their dentist(advertising in a way). The big controversy brewing with PPO's nowadays is that some insurance carriers are "capping" the fees you can charge their members for procedures NOT covered by the insurance plan, whereas in the past, if it wasn't a procedure covered on their reimbursement fee schedule you could bill the patient the full amount of your "regular fee" and the patient would be responsible for the full amount. This is a new trend that's just starting in the insurance industry and is a bit concerning IMHO.

A HMO/DMO basically operates on volume and for the economic health of your practice, hopefully the lack of patient utilization of their plan. Basically, you get paid a flat fee per month per patient to take care of whatever they need. The more patients you have enrolled and the less treatment they need, the greater your profit - I don't think I need to explain how this can be a problem (or possibly work).

I won't say that any type of insurance plan is necessarily "bad", it's just that some(or maybe none) will work better for dentists in certain areas and with certain types of practices.

 

[Visceral]

You kind of need to make a distinction between a FFS (fee for service) and PPO (Preferred Provider) and a HMO/DMO type plan, especially the later 2 because they are definately different and definately have their places if that's how one is comfortable practicing.

In the PPO, if you enroll with that insurance company/companies that are offering one, you agree to accept the fee schedule that they are offering independent of what your "normal" fee is and you can't then bill the difference in most plans (for example, if your usual fee for a 1 surface amalgam was $100, and the PPO you were enrolled in set their UCR (Usual, Customary and Reasonable) fee for that procedure at $90 - you'd be re-imbursed thr $90 and would write off the extra $10. For doing this, you'd be listed as a "Preferred Provider" with that insurance company and folks enrolled with it in your area would see your name and hopefully select you as their dentist(advertising in a way). The big controversy brewing with PPO's nowadays is that some insurance carriers are "capping" the fees you can charge their members for procedures NOT covered by the insurance plan, whereas in the past, if it wasn't a procedure covered on their reimbursement fee schedule you could bill the patient the full amount of your "regular fee" and the patient would be responsible for the full amount. This is a new trend that's just starting in the insurance industry and is a bit concerning IMHO.

A HMO/DMO basically operates on volume and for the economic health of your practice, hopefully the lack of patient utilization of their plan. Basically, you get paid a flat fee per month per patient to take care of whatever they need. The more patients you have enrolled and the less treatment they need, the greater your profit - I don't think I need to explain how this can be a problem (or possibly work).

I won't say that any type of insurance plan is necessarily "bad", it's just that some(or maybe none) will work better for dentists in certain areas and with certain types of practices.

Thanks a lot! This really clarifies things.