Dental billing and insurance companies are two sides of a coin. In today’s world, every patient uses insurance plans to cover their treatment charges. With thousands of insurance companies in the US market, it could be difficult for health professionals to decipher fee standards and various related norms laid out by them. In this article, we’ll be covering general categories and related norms of dental fee layouts that are followed by the insurance companies.
Preferred Provider Organizations (PPO): PPO is the most common category where the health professionals sign a contract with insurance companies that include defined payment structures for various treatments which could be claimed by in-network health professionals. Even though these policies apply for in-network and non-network dentists,the in-network professionals enjoy much more benefits when compared to non-network dental professionals. However, the in-network doctors are liable to demand only the maximum fees that have been contracted with the insurance companies. On the other hand, non-network doctors have the authority to demand fees as per their liking. In this case, insurance companies are not liable to pay any extra amount if charged by the dental professional. Moreover, there are certain norms set out by the insurance companies which mold the practice pattern of the dental practitioners. For instance, a dentist might have to choose a cheaper alternative of treatment, if possible. If a dental professional deviates from the norms, they are notified by the payer.
Following are the payment norms of Preferred Provider Organizations:
Dental Health Maintenance Organization (DHMO) Capitation Plan: DHMO Capitation Plans is another well-known option that dental professionals opt for when it comes to insurance plans. As per the DHMO capitation plan, every dental professional who participates in the plan is liable to get a prepaid amount every month. This amount is subject to the number of patients designated to the dental professional by the insurance company. This contract then further accounts for dentists to provide the treatments to the patients at either no-cost or at a reduced cost. These plans apply only to in-network dentists and do not reimburse any claims made by non-network dental professionals. The major benefit of such plans is that dental professionals get a certain amount each month even if services are rendered or not.
Following are the payment norms of DHMO capitation plans:
Indemnity Plans: These plans work in a traditional way, where claims are submitted by the dental professionals for the provided services, and when cleared, these claims are reimbursed by the insurance companies. In most of the indemnity plans, patients can choose their own dentists, and equal benefits are applicable for both in-network and non-network dental professionals. However, in some scenarios, indemnity plans can be paired with PPO for additional benefits. Additionally, even though the dental professionals have the authority to demand their own fees, these plans reimburse the claims as per UCR (Usual, customary, & reasonable fees), which depends upon the patient’s insurance plan.
Following are the payment norms of Indemnity Plans:
Direct Reimbursement: In these plans, the patient chooses a dentist as per their liking, funds their treatment, and further submits the receipt of the rendered treatment to claim the insurance benefits. In such cases, dental practitioners do not have to go through the claim submission process. Furthermore, dentists are allowed to charge for treatments as per their liking and make treatment decisions after discussing with the patient without any need for explanation to the insurance companies.
Point of Service Plans: In such plans, patients seek dental assistance from out-of-network dentists, and reimbursements are done to the patients. Similar to direct reimbursement, dental professionals do not have to go through the claim submission process. However, very few patients opt for such plans as the benefits of such plans are very limited, especially for the patients.
Referral Plans: Also known as discounted plans, these plans are not typically insurance plans. In these plans, a company signs a contract with a network of dentists where these professionals agree to provide treatments at a discounted rate. No further claim procedures are required in such plans.
Exclusive Provider Organizations (EPO): These insurance plans only reimburse dental claims for the professionals that participate in their plans. Such plans are not popular as they constrict the choice for patients and dental care options for dentists & patients respectively.
Schedule of Allowances Plan: These plans are similar to indemnity plans. The difference in such plans is that they reimburse a certain decided amount of a procedure irrespective of the actual charges. The difference in the charges is the patient's responsibility that has to be covered by the patient. Furthermore, these plans can also be paired with PPO for maximum benefits.
