An Explanation of Third Party Payment for Dental Care

In recent years there has been a significant increase in so-called “managed dental health care”, in which insurance groups make contacts with local companies to provide dental care for specified fees and with numerous regulations and stipulations for patients.  Your employer may decide to provide dental benefit for you using a managed care program.  The following information will help you to understand the managed care concept and its advantages and disadvantages.

Other than paying for dentistry yourself without any involvement with insurance companies, there are several payment concepts currently popular:

PPO (Professional Provider Organization)

These organizations offer dentistry at reduced fees as provided by specified practitioners.

A dental benefit company (PPO) contracts with your employer to provide dental care for you.  The dentists who participate in the PPO plan agree to treat you for significantly reduced fees.  They are called “preferred provider”.  Usually only a few dentists in any community participate.  Often they are younger dentists or a few mature dentists who have various reasons for their participation.  Many dentists do not participate in PPOs, because the reduced fees limit the dentists’ ability to provide services at their usual level.

Dental benefit companies administering PPOs are in business for profit.  The profits go to the PPO owners.  With the myriad of new innovations in dentistry, it is impossible for updated practitioners to provide high-level standard of care services on a continuing basis to you at reduced fee levels.  Be careful!  If you elect to join one of these plans, you can expect only maintenance level care.  Elective services such as implants, aesthetic dentistry, orthodontics and other treatment may not be covered.

HMO (Health Maintenance Organization)

These organizations offer minimal dentistry at low fees by specified practitioners.

Perhaps the greatest current threats to quality dental care in the U.S. are the currently popular, under-funded dental HMOs.  A dental benefit company (HMO) makes a contract with your employer to provide overall dental care for you at unbelievably low fee levels.  Capitation payments to dentists from many dental HMOs will not even provide the total of two dental “cleanings” (scaling and polishing) per year.  The dentist receives a few dollars per patient per month, whether the patient is treated or not.  Obviously, the dentist would rather not see the patient, and certainly would not rather do any expensive treatment, almost all of which must be donated to the patient by the dentist.

Generally in dental HMOs, the dentist can only survive financially by not treating the patients.  Who profits from dental HMOs?  Certainly not the patient or dentist.  You guessed it – the HMO owners!  As in some PPOs, if you elect to join a dental HMO, you have a group of preferred providers who participate in the plan for various reasons.

On the other hand, there are a few large dental HMOs with historical evidence of relatively acceptable levels of dental care.  However, these are exceptions to the previous statements.  Your dentist can easily tell you if the dental HMO plan you are considering provides adequate funding for dental services.

Traditional Indemnity Dental Insurance Plans

These organizations offer standard dental treatment at normal fees with a choice of practitioners.

These groups are the original managed care organizations in dentistry.  Many dental patients have been on these plans for decades.  They provide payment to dentists at fee levels that generally allow quality oral services to be provided.  One of the only disadvantages to some of these plans is the high administrative cost charged to you and your employer.  Thus, you receive less dentistry than the funds your employer pays into the benefit company.

Nevertheless, traditional “fee-for-service”, freedom of practitioner choice, dental insurance plans have provided excellent dental services for Americans for decades.

Direct Reimbursement

A newer form of payment called Direct Reimbursement (DR) can be obtained by your employer, in which you have complete freedom of choice about practitioners and the quality level or type of service you want, without major cost to your employer.  We will be pleased to provide information on DR if you want it for your employer.

Americans enjoy freedom in nearly all areas of their lives.  We think you want to choose your health practitioner based on your own criteria, and you want the very best preventive care and treatment you can get.  We doubt if you trust profit motivated companies to select your practitioners, dictate their fees, or limit the services.  Only two of the four methods of payment described above preserve “freedom of choice dentistry” (traditional indemnity dental “insurance” plans and direct reimbursement.

Thank you for your support. We look forward to serving you with high quality, moderate cost, freedom of choice dental services.

Scott F. Kenward, DMD
Osvaldo Z. Mayoral, DMD