Provider plans made easy

Dental preferred provider organizations
Dental PPOs are most commonly a network of participating dentists that have agreed to provide covered services at reduced rates agreed upon in advance. Participating dentists join DPPOs for increased patient volume, automatic assignment of benefits and more efficient reimbursement of fees. In a DPPO, employees and dependents receive optimized benefits for services when they select a dentist in the network. They may go out of the network if they wish, but the member’s benefits may be reduced, out-of-pocket costs may be increased and benefits may not be automatically assigned to the dentist. When there is no assignment of benefits, the patient generally pays the dentist up front, and then files a claim directly with the carrier to seek reimbursement.

Dental health maintenance organizations
Dental HMOs typically pay dentists providing the services on a capitated, or “per head,” basis. In this scenario, the contracted dentist provides covered services and in return receives a specific dollar amount on a periodic basis, usually monthly, for each covered individual or family enrolled in the dental office. Some DHMOs compensate dentists on a fee-for-service, or “per service” basis, where the contracted dentist agrees to provide covered services at reduced rates agreed upon in advance. Others may use a hybrid form of compensation that includes a combination of both capitation and fees for certain services.

Most DHMO plan contracts also include patient copayments on selected procedures. In most states, DHMO contracts are required to comply with state-specific regulatory provisions that can affect various contractual provisions.

Discount dental plans
Dentists in DDPs agree to perform services for enrollees at a specified discounted price or a percentage discount off of their usual charge. No payment is made by the DDP to the dentists; dentists are paid the negotiated fee directly by the enrollee.

The growth of discount dental plans is in part a response to the scarcity of insurance products in certain parts of the country marketed to individuals by dental plans, and the growing consumer demand to control dental health care costs. By creating an inexpensive vehicle to increase access to more affordable dental care, discount dental plans aim to successfully meet the demand of many dentally uninsured and underinsured Americans.

Because discount products do not pay benefits, no claims are generated. These products are typically not regulated in the same manner as insurance carrier products.