3. o -Fee for service basis,
o -Patient receives specific services and pays
the provider directly,
o - As costs of health care continue to rise
majority people can’t afford dental
treatment.
o -Methods to easy costs by - legislation
-development of
variety of funding approaches.
4. 1.Fee for service
2. Post payment plan
3. Private third party prepayment plans-
a. Commercial insurance company
b. Nonprofit health service corporation-
i. Delta dental plan
ii. Blue cross/blue shield
c. Prepaid group practice, including health maintenance
organization [HMO]
d. Capitation plan
4. Salary
5. Public programs
5.
6. ~The most common method.
~Private fee for service also called as ‘two-party
arrangement’ is the traditional form of
reimbursement for dental service.
~Patient takes an appointment and dentist suggest
the appropriate treatment and informs the
patient his fee for the service.
~Patient is responsible to pay fee.
1.FEE FOR SERVICE
7. Advantages & Disadvantages of fee for
service-
Advantages
1. It is culturally acceptable: Most common method of doing business.
2. It is flexible:The dentist can modify his fees according to market condition and can
also practice ‘price discrimination’ (some patients, e.g. wealthier ones pay more
than others for the same service).
3.Administratively simple: the dentist may not always keep a written list of fees for
various procedures.
Disadvantage
1.There are many patients who due to cost of treatment maystill not be able to
afford the treatment under this method of payment.
8. ~Patient borrows money from a bank/finance
company to pay the dentist fee, at the appointment
when agreement to receive the care is made.After,
the application is approved by the bank, the entire
fee is paid to the dentist.The patient then repays
the loan (with interest) in the budgeted amount to
the lending institution.
~Also called as budget payment plans.
~Not so beneficial for patients with defaulted loans &
low income.
2.POST PAYMENT PLANS
9.
10. Defn- Third party payment is defined as payment for
services by some agency rather than directly by the
beneficiary of those services.
~Dentist- First party ;
Patient-Second party ;
Administor of the finances-Third party.
~Third party is also known as the carrier, insurer,
underwriters or the administrative agent.
~The purchaser of this type of plan can be organized
private group e.g., a union or it can be an employer,
a governmental agency or a union employer welfare
fund.
~In private third party plans, premiums are collected
to meet the costs providing care as well as the
administrative cost of the third party.
3.PRIVATE THIRD PARTY PREPAYMENT
PLANS
11. 3. Private third party prepayment plans-
a. Commercial insurance company
1- Usual, customary & reasonable(UCR)fee,
2-Table of allowances,
3- Fee schedules,
4-Capitation.
b. Nonprofit health service corporation-
ii. Blue cross/blue shield
c. Prepaid group practice, including health maintenance
organization [HMO]
d. Capitation plan
i. Delta dental plan
13. 3.a.Commercial insurance company
~Dental insurance is turned potentially
profitable area of business.
~ To be insurable, a risk must-
1. Be precisely definable
2. Be of sufficient magnitude that if it occurs, it
constitutes a major loss
3. Be infrequent
4. Be of an unwanted nature
5. Be beyond the control of the individual
6. Not constitute a moral hazard. ie_should not lead to additional
claims
14. Reimbursement of dentists in prepayment
plans-
1- Usual, customary & reasonable(UCR)fee,
2- Table of allowances,
3- Fee schedules,
4-Capitation.
15. ~Types of payments offered by insurer
* Deductible
* Co-insurance/Co-payment
* Group insurance
Deductible : It is a stipulated flat sum that the patient
must pay toward the cost of treatment before the
benefits of the program go into effect. Called as front-
end-payment.
Co-insurance: Co-insurance is defined as "an
arrangement under which a carrier and the beneficiary
are each liable for a share of the cost of the dental
services provided”. ie_pt pays % of total cost of treatment.
Group Insurance :This is health insurasnce offered
only to groups.
16. 3.a.1- Usual, customary &reasonable (UCR)
fee,
American Dental Association (ADA) prefer the Usual,
Customary and Reasonable [UCR] fee method for
reimbursement for dentist in prepayment plans.
Usual fee :The fee usually charged for a given service by an
individual dentist to private patients i.e., his or her usual fee.
Customary fee :A fee is Customary when it is in the range of
the usual fee charged by dentists of similar training and experience
for the same service within the specific and limited geographic
area.
Reasonable fee :A fee is reasonable if it meets the above two
criteria or if it is justifiable considering the special circumstances or
the particular patient in question.
17. 3.a.2-Table of allowance
It is defined as a list of covered services that assigns to
each service a sum that represents the total obligation
of the plan with respect to payment for such service,
but that does not necessarily represent a dentist’s full
fee for that service.
Eg. _ dentist’s usual fee -Rs1000,
plan lists for that service a fee - Rs700 , after providing
service Rs700 from carrier & may charge pt. Rs300.
# Not entirely satisfactory because the patients are
often unaware that the plan may not cover them in full
for dental care.
18. 3.a.3-Fee schedules
It is defined as a list of the charges established or
agreed to by a dentist for specific dental services.
Also called as service plan.
Dentistry opposes fee schedule because of following
reasons:
1.Their potential inflexibility, i.e. fees listed can fall below the
customary fees, particularly in times of rapid inflation.
2.The assumption that all dentist’s treatment is of the same
quality and therefore worth the same fees.
3.The fear that their autonomy is threatened, specially if the fee
schedule is not controlled by dentist.
19. 3.a.4-Capitation
It is defined as a fixed monthly or yearly
payment paid by the carrier to the dentist
in a closed panel, based on number of
patients assigned to the dentist for
treatment.
20. 3.b. Nonprofit health service
corporation
i. Delta dental plans / dental service
corporations: It is a legally constituted not-for-profit
organization that negotiates and administers
contracts for dental care, incorporated on a state-by-
state basis.
~ National Association of Dental Service Plans
(NADSP) was formed in June 1966 with the help
from ADA.The NADSP changed its name to Delta
Dental Plans Association in April 1969.
21. Reimbursement of dentists in Delta plans:
~Exclusively use the UCR concept.
~Participating or non-participating in the plan.
~A participating dentist is defined as any duly licensed
dentist with whom a Delta plan has a contractual
agreement to render care to covered subscribers.
22. Rules –
1. Pre-filing of their usual and customary fees.
2.Acceptance of payment for their services at 90th
percentile of fees as payment in full.
3. Fee audits by auditors from Delta plan, who may
check their office records from time to time.
4. Post-treatment inspection of randomly chosen
patients.
5.The withholding of a small amount of each fee to
go into the Delta capital reserve fund.
*Non-participating dentists can also treat patients
covered under Delta dental plan.They are paid at a
considerably lower percentile than the 90th, often
at the median or 50th percentile.
23.
24. ii. Blue cross/blue shield
These non profit health service
corporations have for years offered
limited dental coverage as a part of
medical policies. Dental coverage was
usually limited to services provided in a
hospital.
Blue Cross / Blue Shield dental plans have
adopted many of the cost control features
pioneered by Delta plans
25. 3.c. Prepaid group practice, including
health maintenance organization
[HMO]
ADA definition states that a nonsolo dentist “works in a practice with at
least one other dentist. Some of these dentists may be employed by the
owner dentist in the practice”.
Advantages for a Dentist Practicing in a Group-
1.Organized lifestyle,
2. Less disruption in practice.
3. Financial fringe benefits such as sick leaves and pension plans can be built.
4. Quality of care is said to be improved because of the built-in peer review.
5. Sharing of the personnel, equipment and other resources make group practice
more economical.
Problems Associated with Group Practice-
1. Dentists considering group practice essentially need to be temperamentally
compatible.
2. Dentists are taught to work independently.
26. Health Maintenance Organizations
(HMO)-
Defn-“A legal entity which provides a prescribed
range of health services to each individual who has
enrolled in the organization in return for a prepaid, fixed
and uniform payment”.
Four basic organizational modes under which dental
care can be provided in an HMO:
-Staff model
-Group model
-Independent practice association(IPA)
-Capitated network or direct contract model
27. 3.d. Capitation plan
~ADA defines it as a dental benefit program in which a
dentist or dentists contract with the program’s sponsor
or administrator to provide all or most of the dental
services covered under the program to subscribers in
return for a payment on a per capita basis.
~A capitation fee is usually a fixed monthly payment paid
by a carrier to a dentist based on the number of
patients assigned to the dentist for treatment,
regardless of whether the participant in the plan
receives care or not.
28. Dentists are paid salary in some group practices.
e.g. those employed by public agency or in armed forces.
*Advantages-
1.An immediate reasonably good salary.
2. Fringe benefits such as health disability insurance and
liability coverage.
3. Retirement plan.
4. Paid vacation time.
5. Freedom from overhead costs and day to day worries of
private practice.
6.A chance to improve clinical experience and speed.
*Disadvantage-
1.Salary may not be as high as peak earnings in private
practice.
4.SALARY
29. Medicare-Part A: Hospital insurance,
Part B: Voluntary supplemental medical
insurance.
Medicate-joint federal state program.
National Health Insurance (NHI)- paid for from a
publicly organized fund.
5.PUBLIC PROGRAMMS
30. 1. Fee-for service
2. Dental Insurance
3. Government schemes-
~ Employees State Insurance Scheme(ESI)
~Central government health scheme(CGHS)
31. The financing of dental care is well developed and well practiced in the
developed countries like the U.S. However, In India, fee-for-service is still
the most prevalent form of availing dental services.Although free dental
services are provided by the government at some of the health centers, it
is scarce and inefficient. Dental insurance is in its infancy and with the very
high premiums, dental service is still very far from the reaches of the
indigent.
32. ❑ATextbook of Public Health Dentistry -CM
Marya .
❑Essentials of preventive & Community
Dentistry –Soben Peter.
