The acceleration in the rate of increase of healthcare costs have been attributed to a number of factors, principally The public’s increasing demand for health services. The ever-growing technology of health care. The probably higher quality of care now being delivered. General inflation. The lack of incentives in medical care to keep costs down. The increasing practice of “defensive medicine” in which diagnostic tests and prescribed treatment are aimed at avoiding lawsuits rather than at meeting the patients real needs. Private Fee for Service the two party arrangement is the traditional form of reimbursement for dental services in most countries Post payment Plans first introduced in the late 1930’s by local dental societies in Pennsylvania and Michigan. It is also known as budget payment plans. . Private Third Party Prepayment for dental services is defined as “payment for services by some agency rather than directly by the beneficiary of those services” 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. The money is paid regardless of whether the patients participate in the plan, receive no care, a little care or great deal of care

1. Payment for
Dental Care
By
Dr Sana Masood

2. Background
The acceleration in the rate of increase of healthcare costs
have been attributed to a number of factors, principally
• The public’s increasing demand for health services. The ever-growing
technology of health care.
• The probably higher quality of care now being delivered.
• General inflation.
• The lack of incentives in medical care to keep costs down.
• The increasing practice of “defensive medicine” in which diagnostic tests
and prescribed treatment are aimed at avoiding lawsuits rather than at
meeting the patients real needs.

3. MECHANISM OF
PAYMENT FOR
DENTAL CARE
Grouped into the following general categories.
1. Private fee for service
2. Post payment plans
• Commercial insurance companies
• Non-profit health service corporations such as delta dental
plans and blue cross/blue shield
• Prepaid group practice including health maintenance
organization and independent practice associations
• Capitation plans
3. Private third-party prepayment plans
4. Salary
• Medicare
• Medicaid
• Veterans' administration (VA)
• National health insurance (NHI)
5. Public programmes

4. 1. Private Fee for Service
• Private fee for service, the two party arrangement is the traditional form of
reimbursement for dental services in most countries
Advantages Disadvantages
• It is culturally
acceptable
• It is flexible
• It is administratively
simple.
• some potential patients
who simply cannot afford
the dental care offered.
These persons would thus
be unable to pay

6. 2. Post payment Plans
• first introduced in the late 1930’s by local dental societies in Pennsylvania and Michigan.
• It is also known as budget payment plans.
patient borrows money from the bank
After the application is approved by the lending
institution
the dentist is paid the entire fees less a discount
charge.
The patient then repays the loan (with interest
of course) to the bank in budgeted amounts.

7. 3. Private Third Party Prepayment Plans
• Third party payment for dental services is defined as “payment for services by
some agency rather than directly by the beneficiary of those services”
Dentist and
patient is second
party
Administrator of
finance is third
party

8. Reimbursement of Dentists in
Prepayment Plans
UCR
Customary
fee
Reasonable
fee

9. • The ADA is opposed to
1. Capitation
2. Fee schedules
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

10. Capitation
Fee
Schedules
• 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.
• The money is paid regardless of
whether the patients participate in the
plan, receive no care, a little care or
great deal of care
• A fee schedule is defined as
maximum dollar allowances
for dental procedures that
apply under a specific
contract.
• The difference is that a fee
schedule is usually taken to
mean payment in full,
whereas a table of allowance
may not.

11. a. Commercial Insurance Companies
Commercial insurance companies have become competitive through a variety of other
mechanisms
• They can be more selective about the group to which it chooses to offer dental insurance.
• They claim no obligation towards the dental health of the community.
• They sometimes arrange an identity programme, which provides specific cash payment
reimbursement for specified covered services.
• These payments can be made directly to the patients or it can be assigned by the patient to be
paid directly to the dentist.
• They present attractive total health package to potential purchasers

12. Advantages Disadvantages
1. Many pay the dentist directly for
provision of covered services and
hence payment is quicker and hassle
free.
2. They do not conduct fee audits and
posttreatment dental examinations to
assess the quality of care delivered.
1. They do not encourage
utilization of professional
services.
2. In order to allow for the
profit margin they need
to charge higher
premiums.

13. c. Prepaid Group Practice
• The term group practice simply means a number of dentists practicing together
under certain organizational arrangements.
• The definition adopted by ADA is as follows: “Group practice is that type of
dental practice in which dentists, sometimes in association with the members of
other health professions, agree formally between themselves on certain central
arrangements designed to provide efficient dental health service.”

14. Advantages Disadvantages
• Better ways of organizing one’s
life-vacations and continuing
education leaves can be planned
more readily.
• Less disruption in practice
caused by illness to the dentist.
• Quality of care is said to be
improved.
• Financial fringe benefits.
• Economies of scale through the
sharing of pieces of equipment,
personnel and other resources.
• Personality: It is essential that
dentist in a group be
temperamentally compatible.
• Dentist unlike physicians are
taught to work independently
and this desire for
independence is one reason
suggested for the slow growth
of dental group practice

15. d. Health Maintenance Organisation (HMO)
• An HMO is defined as “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
Dental personnel in HMO
1. Staff model: Dentists, dental hygienists and dental assistants are salaried employees of
the HMO.
2. Group model: The HMO contracts directly with a group practice, partnership or
corporation for the provision of dental services
3. Direct contract model: The HMO contracts directly with the individual provider for
provision of services.
• Independent practice association It is an association of independent dentists that
develops its own management and fiscal structure for the treatment of patients
enrolled in an HMO.

16. e. Capitation Plans
• 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. The money is paid regardless of
whether the patients utilize care or not.

17. CLOSED
PANEL
OPEN
PANEL
• Closed panel practice exists
when a group of dentists who
share office facilities provide
stipulated services to an
eligible group for a set
premium.
• For beneficiaries of plans
using closed panels, choice of
dentist is limited to panel
members, and dentist must
accept any beneficiary as a
patient.
• Any licensed dentist can
participate, the beneficiary has
choice from among all licensed
dentists, and the dentist may
accept or refuse any
beneficiary.

18. 4. Salary
• Dentist in some group practices (especially closed panel clinics), those in the armed
forces and those employed by public agencies are salaried. A new graduate
beginning a career in an established practice may draw a salary for a temporary
period.
Advantages Disadvantage
• Dentist will be largely free of
the business concerns of
running a practice and thereby
allows the dentist to
concentrate on clinical matters.
• Fringe benefits are also often
attractive.
• Lack of financial
incentives.

19. PUBLIC PROGRAMMES
• a. Medicare
Title XVIII of the social security amendments of 1965 is the programme known as
Medicare. This programme removed all financial barriers for hospital and
physician services for all persons over age 65, regardless of their financial means.
• b. Medicaid
Title XIX of the social security amendments of 1965 is the programme known as
Medicaid. The original intent of the programme was to provide funds to meet the
healthcare needs of all indigent and medically indigent persons

20. Conclusio
n
• Private fee for service is likely to remain the predominant method of financing
dental care in the foreseeable future.
• The developing countries are in a transition period, during which alternative
modes of delivery of services and financing of these services will evolve.

21. References
Preventive and Community
Dentistry By Josphe john