Types of Dental Practices [Fee For Service, ?, ?]

[DrTacoElf]

Hey guys i'm shadoinwg a general dentist who is fee for service, but i'm not sure exactly what this means. Also if you are not fee for service what are you options and what about accepting insurance. What are the pros/cons of each. How does managed care fit into dentistry?

Any website links explaining this would be superb 🙂
Or if you willing to explain that would be great also.

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[aileen]

I find it extremely hard to comprehend insurance system. Maybe that's the whole point. Insurance carriers do not want us to know.

To my understanding, there are 2 big categories: HMO and PPO. PPO is called "fee for service". You bill the insurance for services you perform and get paid according to the contract amount or fee. If you're out of network, you can also bill the patient for the difference.

HMO is the managed care (capitation). The member picks a dentist from the network and can go see him only, no other dentists. The insurance company pays the designated dentist certain amount of money, say every month per patient. If the patient doesn't have dental problems and not see you often, you get paid for doing nothing. HOWEVER, if the patient has a lot of work to be done, you'll be doing all that work at the fixed amount of money (capitation, some pays $5/person, some pays $35/person) you receive from the insurance. The insurance will not pay you extra for doing that. That sucks. Dentists would not want to see their HMO patients and might under-treat them.

NYC tried to cut the medicaid cost by converting from PPO to HMO. Now many medicaid members have to pick an insurance carrier like HIP, Health Plus, Metroplus, Health First, etc. These insurance companies put the members under HMO including dental. However, it didn't take too long for dentists to cancel their contracts with HMO companies and stop seeing HMO patients. Do you think it makes sense for small practices to receive $9/person (that's what HIP pays) and do 3-4 root canals and crowns? No dentists in their right mind wanted to do that. Now those insurances offer PPO dental. Even though their fees are low, it's still better than capitation money. I think it was great for dentists to turn down HMO's and not be bossed or intimidated by them.

Hope that helps. Correct me if I'm wrong.

 

[DrTacoElf]

So it seems that HMO promotes lazyness and care neglect. Where as PPO puts more $ stress on the patients, but gives them better dental care. Then you have those dentists who take HMO and still attempt to give it thier best treatment options and lose money?>

Also it seems that HMO would encourage extremely high patient volumes where as FFS would keep this in better equilbrium?

comments?

 

[UBTom]

Actually, PPO is PPO... The scheme works in the following way: The insurance company wants to entice you the dentist to sign up with their program as a preferred provider and charge lower fees in return for guaranteed patients. If you sign on with the preferred provider organization (PPO), you are limited to charging whatever they dictate (their "usual and customary fees") when you see a patient who has a dental plan with that insurance company.

Fee-for-service is the most straightforward arrangement-- You perform a procedure, the patient pays you without going through a third party (insurance company), and is THE best way to do business.

Dental insurance is one of the most profitable rackets for an insurance company-- They collect premiums, AND limit the amount of dental care a patient is allowed to receive (there is a yearly limit on how much they cover) AND make life hard for us dentists. Basically all they do is leech a profit off the patient AND the dentist.

Fee-for-service makes much more sense for both the patient and the dentist. What the ADA is trying to promote right now is to have companies which want to arrange dental benefits for its employees to set up plans directly with the dentist (and bypass the insurance companies altogether). That way, all the money goes directly into dental care without having an insurance company leech off part of it AND limit access to care.

HTH!