HMO vs PPO vs EPO: What’s the Difference

What insurance plans do you accept? HMO vs PPO vs EPO helps in choosing one over the other. Unfortunately, getting tripped is common when you have different plans that you don’t understand. However, dealing with insurance recurrently and correctly makes claim submissions non-negotiable.
The blog by Capline Dental Services clarifies dental insurance, which sometimes feels monotonous.

HMO vs PPO vs EPO: The Distinction

Health Maintenance Organizations are insurance plans for dental treatments. Receiving a negotiated fee for dental treatment is only possible when the dentist is in-network. The set copay amount is the beneficiary's responsibility, while the HMO covers the remaining cost of the procedures. This is similar to any regular medical insurance.

HMOs have a closed-panel network, meaning the health benefits in the form of services are limited to patients through providers under contract with the plan. This limits services provided by other providers, except in emergencies. Participating providers accept a specific insurance plan and the benefits it offers.

What is a PPO Insurance, and is it Worth the Cost?

A Preferred Provider Organization (PPO) is a type of insurance plan that requires no referrals. Patients have more options with the in-network or out-of-network providers, unlike other plans. PPO ensures higher deductibles and copays. An out-of-network provider leads to an out-of-pocket percentage as the patient’s responsibility. It is subject to the employer's plan or a self-funded plan.
Patient's autonomy is respected. PPO insurance goes beyond the network list of offices around the patient’s area that accept all types of insurance.

EPO is an Exclusive Provider Organization that accepts reduced fees or negotiated fees. EPO plans restrict outside network providers from paying full dental service fees, aside from emergencies. EPOs have lower premiums with a smaller network of dentists.
The dental practitioner has to set up each insurance plan differently. And to do that, the understanding is critical. Otherwise, it can affect the submission process, leading to unnecessary denials. Unnecessary denials are draining and require extra work from the team. The team is busy with administrative tasks rather than patient care, scheduling, and resolving patient queries.

Another reason to get hold of the insurance plan is to determine which is the preferred insurance plan for credentialing. The understanding helps to decide which plan to join and which to avoid. There are many other factors, but they largely depend on the practice location and the volume of patients you want to take on.

Pros of HMO vs PPO vs EPO Insurance Plan

• The HMO plan network is confined. There are limited options with providers who will not accept a patient’s insurance. The patients have clarity about the facilities accepting their insurance plan before visiting the office. And providers have no confusion because it has to be one of the insurance plans.
• HMO plans come with lower premiums. They are commonly purchased by patients or offered by their employers.
• PPO has a large network of providers. If patients have a PPO plan, then they have more options for their care. Patients have more choices in choosing a dentist. Simultaneously, the practice receives more business by accepting more insurance.
• Patients have more coverage and fewer out-of-pocket expenses during their clinic visit. PPO is known for its flexibility. The transactions are straightforward between patients and the front desk staff. Patients don’t need a Primary Care Doctor for specific procedures.
• EPO needs no referral and no primary care provider. It is worth noting that EPO has lower out-of-pocket expenses.

Cons of HMO vs PPO vs EPO Insurance Plan

• HMO is less flexible, meaning a smaller network with fewer choices of facilities and providers for patients. Some patients do not appreciate it and tend to stay far from their insurance provider's network. Similarly, dentists need to deal with patients in emergencies when they are not in the network.
• The referral from the PCP is a mandate for special treatments. The need for PCP approval is a drawback for dentists, as it adds an extra point of contact before proceeding with procedures.
• The PPO offers higher monthly premiums, better coverage, and flexibility. Elementary research is needed to verify the insurance plan.
• Patients are responsible for out-of-network coverage, which can lead to unnecessary expenses. EPO has a smaller provider network.

How to Avoid Mistakes with HMO vs PPO vs EPO Insurance Plan

Credentialing with different insurance plans, such as HMO, PPO, and EPO, is common. It expands the patient pool. Getting paid for all the dental claims is challenging. An efficient approach is to outsource dental billing to Capline Services. This ensures the plan is paying you properly. Each type of dental insurance works differently, and you need to handle each plan differently. Filing more claims with the first payout depicts the health of the practice. The fewer mistakes, the better the team's claim.

Mistake 1: Confusion about the Coverage Rules

Without knowing the plan and what fees you can bill, it is hard to bill insurance correctly. The covered fees for the HMO plan $200 plus the lab fee. The lab fee is $500. There is no point in walking away from the reimbursements they are entitled to collect.
Some plans even pay an additional amount for specific procedures, as discussed before the contract. The utilization report from the plan helps the practice determine if the managed care plan is a profit or a loss. Capitation payments and capitation patient reports negligence can affect overhead costs and overall profits.

Mistake 2: Inaccurate Setting of an Insurance Plan

The wrong setting in the practice management software is a disaster. The inaccurate settings make it much harder to pin the claim payments and decipher the patient's financial responsibility. It causes patient dissatisfaction. Figuring everything manually can cause cash problems, waste time, increase overhead, and decrease patient collections, which leads to claim denials.

Mistake 3: Ignorance of Billing Education

Insurance companies make it harder to submit claims for quick reimbursements. Education in insurance billing is powerful, and investing in team knowledge can result in fewer denials. To start the journey from lack of education to proficiency, enroll with Capline Dental Services, where the experts help you optimize the insurance claim income.
Learn more and get your personalized assistance with Capline Dental Service.