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Payment for dental care

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Payment for dental care

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Payment for dental care

  1. 1. DR. M. DHIVYA LAKSHMI
  2. 2. MECHANISM FOR PAYMENT OF DENTAL CARE  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  Salary  Public programs. a) Medicare b) Medicaid c) Veterans Administration d) National Health Insurance
  3. 3. PRIVATE FEE FOR SERVICE  Two party arrangement  Traditional method  Commonly practised ADVANTAGES:  Culturally acceptable  Flexible  Administratively simple DISADVANTAGES:  Some potential patients who cannot afford dental care offered.
  4. 4. POST PAYMENT PLANS  Introduced in late 1930’s by local dental dental societies in Pennsylvania & Michigan.  “Budget payment plan”.  the patient borrows money from a bank or some finance company to pay the dentists fee.  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.
  5. 5. PRIVATE THIRD PARTY PREPAYMENT PLANS  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 ADMINISTRATOR
  6. 6. REIMBURSEMENT OF DENTISTS IN PREPAYMENT PLANS  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
  7. 7. 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 service.
  8. 8. ADA IS OPPOSED TO CAPITATION: 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 FEE SCHEDULES: List of charges established or agreed upon by dentist for specific dental services. Usually taken to mean payment in full.
  9. 9. COMMERCIAL INSURANCE COMPANIES  Operate for profit.
  10. 10. ADVANTAGES DISADVANTAGES COMMERCIAL INSURANCE COMPANIES  Payment is quicker & hassle free.  No fee audits & post treatment dental examination to assess the quality of care delivered.  Do not encourage utilization of services  Charge higher premiums.
  11. 11. 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 dental care. • 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 April 1969. • 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.
  12. 12. Specific approaches to monitor quality care provided and to maintain program’s costs within limits. Board of directors – mostly dentists. Series of post treatment examinations Examined to ensure – a) care claimed & provided has been provided b) Acceptable quality
  13. 13.  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.
  14. 14. REIMBURSEMENT OF 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.
  15. 15. 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’’.
  16. 16. HEALTH MAINTENANCE ORGANIZATION  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.
  17. 17. SALARY  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 attractive.  Disadvantages:-  There could be a lack of financial incentive that some dentists, need to be highly productive.
  18. 18. MEDICARE  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 medical Insurance.  Medicare was brought into being because the voluntary health insurance system was unable to provide adequately for persons over age 65.
  19. 19. MEDICAID  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 indigent persons. 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

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