MECHANISM FOR PAYMENT OF
Private fee for service.
Post payment plans.
Private third party prepayment plans
A) Commercial insurance companies
B) Non profit health service corporations
E.g.: Delta dental plans, blue cross /blue shield
C) Prepaid group practice
D) Capitation plans
c) Veterans Administration
d) National Health Insurance
PRIVATE FEE FOR SERVICE
Two party arrangement
Some potential patients who
cannot afford dental care
POST PAYMENT PLANS
Introduced in late 1930’s by
local dental dental societies
in Pennsylvania &
“Budget payment plan”.
the patient borrows money
from a bank or some
finance company to pay the
After the application is
approved by the lending
institute the dentist is paid
the entire fee. The patient
then repays the loan to the
bank in budgeted amounts.
PRIVATE THIRD PARTY
It is defined as ‘’payment for services by some agency rather
than directly by the beneficiary of those services’’.
1st PARTY - DENTIST 2nd PARTY - PATIENT 3rd PARTY – FINANCE
REIMBURSEMENT OF DENTISTS IN
USUAL, CUSTOMARY & REASONABLE FEE (UCR)
USUAL FEE: The fee usually charged for a given service by an
individual dentist to private patients – his/her “usual fee”
CUSTOMARY FEE: Fee in the range of the usual fee charged
by dentist of similar training & experience for the same service
within the specific & limited geographic area.
REASONABLE FEE: If it meets these 2 criteria
TABLE OF ALLOWANCES
A table of allowances 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
ADA IS OPPOSED TO
A capitation fee is defined as
a fixed monthly or yearly
payment paid by a carrier to
a dentist in a closed panel,
based on the number of
patients assigned to the
dentist for treatment
List of charges established or
agreed upon by dentist for
specific dental services.
Usually taken to mean
payment in full.
Operate for profit.
Payment is quicker &
No fee audits & post
examination to assess the
quality of care delivered.
Do not encourage utilization
Charge higher premiums.
NON-PROFIT HEALTH SERVICE
CORPORATIONS - DELTA DENTAL PLANS
June 1954, the Seattle District Dental Society
Comprehensive dental health care program for children upto 14 years.
A dental service corporation is legally constituted non- profit
organisation incorporated on a state by state basis and sponsored by a
constituent dental society to negotiate an administrator contract for
• The 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
• The underlying philosophy of the Delta Dental Plans is that the dental
practitioners can adapt their traditional practice to meet the demand for
group purchase of dental care.
Specific approaches to monitor
quality care provided and to maintain
program’s costs within limits.
Board of directors – mostly dentists.
Series of post treatment
Examined to ensure – a) care
claimed & provided has been
provided b) Acceptable quality
Mechanism of cost control – co insurance, pre authorisation
procedures for certain treatment and annual limits on specific
items of care.
They have an obligation towards community.
Encourage utilization of services.
DENTISTS IN DELTA PLANS
UCR concept almost exclusively.
A PARTICIPATING DENTIST has contractual agreement with
delta plan to render care to covered subscribers.
Conditions for participating dentists:
Pre filing of usual & customary fee
Acceptance of payment at 90th percentile.
Fee audits by auditors from delta
Post treatment assessment of randomly chosen patients.
NON PARTICIPATING DENTIST: no fee audit, lower
percentile, 50th percentile, or median.
PREPAID GROUP PRACTICE
ADA (1969) has defined grouped practice as ‘’group practice
is that type of dental practice in which dentists, sometimes in
association with members of other health professions agree
formally themselves on certain central arrangement designed
to provide efficient dental health service’’.
HMO is defined as a legal entity which provides a prescribed
range of services to each individual who has enrolled in the
organization in return for prepaid, fixed and uniform payment.
Dentists in same group practised
those in the armed forces and
those employed by public
agencies are salaried.
largely free of the business
concerns of running a practise
Fringe benefits are also often
There could be a lack of
financial incentive that some
dentists, need to be highly
Title xviii of the social
security amendments of
1965 is the program known
as ‘’Medicare’’. This program
removed all financial barriers
for hospital and physician
services for all persons aged
65 and over, regardless of
their financial means.
• 2 parts
• Part A, Hospital Insurance
• Part B, supplemental
Medicare was brought into
being because the voluntary
health insurance system was
unable to provide adequately
for persons over age 65.
It is the name given to title xix of the
social security amendments of 1965.
The original intent of the program was
to provide funds to meet the health care
needs of all indigent and medically
Basic services ,
• In patient hospital care
• Outpatient hospital care
• Laboratory and x-ray services
• Skilled nursing facility services
• Home health services for individuals
aged 21 years and older.
• Early and periodic screening ,diagnosis
and treatment (EPDST) program for
individuals under 21 years
• Family planning services
• Physician services