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3)    TYPES OF DENTAL PLANS  Associates / Network of Specialists



  • Call and confirm if Dentist is a member of local, state and national professional associations so they are required to practice by a set of agreed standards: Orange County Dental Society (OCDS), California Dental Association (CDA) and the American Dental Association (ADA).
    • The OCDS has a passionate PEER REVIEW COMMITTEE who only review your complaints if the treating provider is an active member.
    • As your advocate, I can support the organization of your complaint to submit to PEER REVIEW.
  • Do I want to be able to eat comfortably and effortlessly through life?
  • Is the way my teeth LOOK important to me?   (ASK YOURSELF ...  How much money would you accept to have a front tooth removed and never replaced?  Generally this conversation leads to the fact, you will never spend this much money taking care of your teeth!)   
    • Do you want your teeth to be surrounded by healthy GUMS versus visible roots?
  • Do you know how much bone loss you have now, or if you have any DEEP POCKETS?      (Obtaining your PERIO PROBING CHART history is important!  Ideally; most recent, 3-5 years, and 7-10 years back.   This should only take about 15 minutes of administrative staff time to transfer via email.  REMEMBER, YOU HAVE A RIGHT TO ALL YOUR HEALTH CARE RECORDS.)
    • Am I aware that as I lose bone through aging or other conditions, teeth may become unstable or be lost?
    • Do you know if you've had regular PERIO CHART PROBINGS that provide this information?

FACT - The average tooth root is 13mm, so if you have 5mm ‘bone loss' or pocket measurements, you have 62% of your tooth surrounded by bone, or 38% not supported by bone or that you cannot access to prevent from collecting bacteria.     

FACT - Dental practice overhead generally averages 65% of gross production.    If a practice is ‘saving patients up to 25%-60% on fees, well... you do the math.   

FACT - Dental practices with over 20% of patients on ‘special discount rate plans COMPROMISE somehow, some way to create profit.   

  • Limit time allowed for procedures. (Ask yourself, do you want a dental hygienist or doctor rushing??)
  • Purchase ‘on sale products' vs their ideal products.
  • They cannot afford to ‘toss' outdated supplies... so they use them.
  • Usually don't' pay or retain experienced staff thereby affecting patient services.

(Excerpt from American Dental Association, ADA, website)

2)  Dental Standards     Dental standards ensure that everyone is on the same page-those who design and manufacture dental products and the dentists who use them. Through comprehensive analysis, the ADA establishes baseline standards and technical recommendations for almost every tool of modern dentistry, from radiographic systems to sealants to manual toothbrushes.     

The ADA'S mission is to ensure the highest level of patient safety and professional satisfaction through the publication of clear industry standards for both dental products and dental informatics. The ADA is the accredited dental standards body of the American National Standards Institute (ANSI) and also designated the official United States representative for the International Organization for Standardization (ISO) Technical Committee 106 Dentistry (TC 106).

Standards and Standards Administration:   The ADA Standards Administration Department (DSA) manages two consensus bodies for standards development: the ADA Standards Committee on Dental Informatics/information (SCDI) and the ADA Standards Committee on Dental Products (SCDP). The ADA is also the sponsor and secretariat of the United States Technical Advisory Group to ISO Technical Committee 106 Dentistry (U.S. TAG for ISO/TC 106).   

The ADA is an ANSI accredited standard developing organization. ADA standards have been approved as American National Standards by ANSI and thus they are designated as ANSI/ADA Standards. Further, ANSI is the U.S. member to ISO. The U.S. TAG for ISO/TC 106 determines the U.S. vote on all dental standards and provides this input to ANSI for ISO/TC 106.

3)    Types of Dental Plans

With so many dental benefit plans available to patients today, it's important to learn the differences between them. Some plans require your dental practice to be part of a network, others limit maximum charges and many have set fees for specific services.  

PROVIDERS? -  Research background and affiliation with dental practice!   Will the PROVIDER be available should you require follow up care?   When, how often, are they scheduled in the office? Are they only in on an 'appointment/needs basis?'  (Short term associates, or part time/contract specialists often work 'by appointment' in several offices and will not be available to 'stand behind their treatment.'    (Ask yourself ... if you have pain requiring a root canal, do you want to be on pain medication 'waiting' for specialists to come to the office, or would you like to go to a local specialist right away?)   You can generally rely on a provider standing behind treatment minimally up to five years' ... this is reflected in a carriers five year requirement to 'replace' a procedure.)    

Created by the ADA's Council on Dental Benefit Programs, it includes information about the management of dental plans, communicating with third-party payers, handling coordination of benefits.

 1. Preferred Provider Organizations (PPO)

A PPO plan is regular indemnity insurance combined with a network of dentists under contract to the insurance company to deliver specified services for set fees and according to the provisions of the contract.

Contracted dentists must usually accept the maximum allowable fee as dictated by the plan, but non-contracted dentists may have fees either higher or lower than the plan allowance.

2. Dental Health Maintenance Organizations (DHMO)/Capitation Plans

Under a DHMO or capitation plan, contracted dentists are "pre-paid" a certain amount each month for each patient that has been designated or assigned to that dentist. Dentists must then provide certain contracted services at no-cost or reduced cost to those patients. The plan usually does not reimburse the dentist or patient for individual services and therefore patients must generally receive treatment at a contracted office in order to receive a benefit.

3. Indemnity Plans

An indemnity dental plan is sometimes called "traditional" insurance. In this type of plan, an insurance company pays claims based on the procedures performed, usually as a percentage of the charges.  Generally, an indemnity plan allows patients to choose their own dentists, but it may also be paired with a PPO.  Most plans have a maximum allowance for each procedure referred to as "UCR" or "usual, customary and reasonable" fees. 

4. Direct Reimbursement (DR®)

Benefits in this type of plan are based on dollars spent, rather than on the type of treatment.  Direct
Reimbursement is a self-funded plan that allows patients to go to the dentist of their choice.  Depending on the plan, the patient pays the dentist directly (or the benefit may be directly assigned to the dental office) and then submits a paid receipt or proof of treatment.  The administrator then reimburses the employee a percentage of the dental care costs.  With some plans there are no insurance claim forms to complete and no administrative processing to be done by the dental office or an insurance company.

5. Point of Service Plans

Point of service options are arrangements in which patients with a managed care dental plan have the option of seeking treatment from an "out-of-network" provider.  The reimbursement to the patient is usually based on a low table of allowances; with significantly reduced benefits than if the patient had selected an "in network" provider.

6. Discount or Referral Plans

Discount or referral plans are technically not insurance plans. The company selling the plan contracts with a network of dentists.  Contracted dentists agree to discount their dental fees.  Patients pay all the costs of treatment at the contracted rate determined by the plan and there are no dental claim forms to file.  Originally these plans were sold to individuals; however, more and more employers are purchasing these types of plans as the dental plan for the company's employees.

7. Exclusive Provider Organizations (EPO)

Exclusive provider organization plans require that subscribers use only participating dentists if they want to be reimbursed by the plan.  These closed panel groups limit the subscriber's choice of dentists and also can severely limit access to care.

8. Table or Schedule of Allowances Plans

These types of plans are indemnity plans that pay a set dollar amount for each procedure, irrespective of the actual charges.  The patient is responsible for the difference between the carrier's payment and the charged fee.  The plan may also be paired with a PPO that limits contracted dentists to a maximum allowable charge.Enter content here

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