FINANCE IN DENTAL CARE

FINANCE IN DENTAL CARE


 INTRODUCTION:-
Health care services traditionally have been provided on a free-for-service basis whereby the patient receives specific services and pays the provider for them directly.

 MECHANISM OF PAYMENT FOR DENTAL CARE:-
The mechanisms by which dental practitioners receive payment for their services can be grouped not,
1. Private free for service.
2. Post payment plans.
3. 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.
4. Salary
5. Public Programs

 PRIVATE FEE-FOR-SERVICE
Private fee-for-service the two-party arrangement is the traditional form of reimbursement for dental services.

Advantages:-
• It is culturally acceptable.
• this system is flexible fees can be changed in accordance with market conditions and the dentist is also able to practice what is called “price discrimination”
• it is administratively simple. Since dentists need not keep a written list of fees for procedures.
• It is the only system under which some form of dental care likely will ever be provided.

 POST PAYEMENT PALNS:-
Post payment or budget payment plans are mechanisms for the individual purchase of serive, while dentists have frequently arranged to allow payment for dental care to be made at intervals over a period of time.

 PRIVATE THID PARTY PREPAYMENT PLANS:-
It is defined as payment for services by some agency rather than directly by the beneficiary at those services.

INSURANCE PRINCIPLE AND DENTAL CARE:-
• Be precisely denfinable.
• Be of sufficient magnitude that if it occurs, it consutitutes a major loss.
• Be infrequent.
• Be of an unwanted nature.
• Be beyond the control of the individual
• Non constitute a “Moral Hazard”

INSURANCE COMPANY HAS FOUND THAT DENTAL INSURANCE CAN BE MADE MORE FEASIBLE BY:-
• Have patient share the cost.
• Limit the range of services available.
• Offering services only to groups.
• Include “Waiting period” after enrollment before benefits become payable.
• Use preauthorization and annual expenditure limits.

Different types of payments offered by the insurer are,
• Deductible.
• Co-insurance
• Group Insurance.

DEDUCTIBLE:-
It is a stipulated flat sum that the patient must pay toward the cost of treatment before the benefits of the program go into effect. It is sometime called “front-end-payment”.

CO-INSURANCE:-
It is called as “co-payment”. It means that the patient pays a percentage of the total cost of treatment. Insurance carriers limit the range of health care services covered. This is termed, “limitation of benefits. E.g. a patient has to pay 20% of the cost of hospital care, the remaining 80% will be paid by insurance company.

GROUP INSURANCE:-
This is health insurance offered only to group. This is because illness experience is reasonably predictable in a group.

REIMBURSEMENT OF DENTISTS IN PREPAYMENT PLANS:-
The ADA has consistently supported the concept of usual, customary and reasonable (UCR) fee as the preferred method for reimbursement for dentists in prepayment plans. Apart from UCR fees, the only other form of payment plans is the table allowances.
• Usual Fee.
• Customary Fee.
• Reasonable Fee.
• A table of allowances.

COMMERCIAL INSURANCE COMPANIES:-
Characteristics:-
• They can be more selective about the group of which it chooses to offer dental insurance.
• They claim no obligation toward the dental health of the community.
• They sometimes arrange on indemnity program that provides specific cash payment reimbursement for specified covered services.
• Commercial insurance companies organize their levels of reimbursement differently.
• Commercial companies do not conduct fee audits and post treatment dental examinations.


DELTA DENTAL PLANS:-
Delta dental plan is synonymous with dental service corporation. A dental service corporation is a legally constituted non-profit organization incorporated on a state-by-state basis and sponsored by a constituent dental society to negotiate and administer contracts 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.

REIMBURSEMENT OF DENTISTS IN DELTA PLANS:
Delta dental plans almost exclusively use the UCR concept.
• Pre-filling of their usual and customary fees.
• Acceptance of payment for their services at 90th percentile of fees as payment in full.
• Fee audits by auditors from delta plan, who may check their office records from time to time. The purpose is to ensure that the dentists are indeed charging their delta plan patients the same fees as they charge their other patients.
• Post –treatment inspection of randomly, chosen patients to monitor the quality of care.
• The withholding of a small amount of each fee to go into the Delta capital reserve fund.

BLUE CROSS / BLUE SHEIELD:-
Blue cross / shield dental plans have adopted many of the cost control features pioneered by Delta plans.

PREPAID GROUP PRACTICE:-
ADA (1969) has defined group practice as “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”.

TYPES OF GROUP PRACTICE:-
• General practice group composed entirely of general practitioners.
• Single specialty groups where all members of the group are of the same specialty.
• Multi- specialty groups where certain practitioners in two or more specialty fields of practice.

HEALTH MAINTENANCE ORGANIZATIONS (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.
The four principles that characterize an HMO are,
An organization system of health care that accepts the responsibility to provide or otherwise assure the delivery of (2) an agreed-upon set of comprehensive health maintenance and treatment services or (3) a geographical area and (4) is reimbursed through a pre-negative and fixed periodic payment made by or on behalf of each person or family enrolled in the plan.
• An organized system.
• Comprehensive health maintenance and treatment services.
• An enrolled group.
• Reimbursement.
Dental personnel in HMO’S:-
• THE STAFF MODEL.
• THE GROUP MODEL.
• The independent practice association (IPA)
• The primary care capitates network or direct contract model.

CAPITATION PLANS
The basis of capitations is that the contracting provider, whether an HMO, group practice, IPA or individual dentist receives an established, negotiated sum on a monthly or yearly basis for each eligible patient.

 SALARY:-
Dentists in some group practices those in the armed forces an those employed by public agencies are salaried.

Advantages:-
• It allows a dentist to be largely free of the business concerns of running a practice, thereby allowing the dentist to concentrate on clinical matters.
• Fringe benefits are also often attractive.

Disadvantages:-
There could be a lock of financial incentive that some dentists need to be highly productive.


 PUBLIC PROGRAMS
Private practice is usually not able to meet the dental demands of all the people. There are therefore a number of public programs aimed at meeting the needs of specific group of recipients in this diverse society. The public programs are sponsored by the government and also include community health centers.

MEDICARE:-
In the USA, title XVII of the social security amendments of 1965 is the program know as Medicare.

MEDICAID:-
It is the name given to title XIX of the united. States Social Security Amendments of 1965.

NATIOAL HEALTH INSURANCE:- (NHI)
The national health insurance was introduced by Bismarck in Germany in the 1880’s and in Britain by Lloyd George in 1910.

PAYMENT FOR DENTAL HEALTH SERVICES IN INDIA:-
The different forms of payment for dental health service in India are
I. Free for Service
A majority of dentists in India provide dental services on a fee for service basis.
II. Dental Insurance
Insurance companies have now started offering dental insurance, which covers not only that dental treatment which requires hospitalization, but also covers dental check ups, oral prophylaxis, restorations and dental extractions. The premium however, varies with the coverage.
III. Government Schemes
Various Government schemes help in Providing Dental / Medical Services to Government Employees.

Employees State insurance scheme (ESI):-
In 1948, a scheme by the act of the parliament for the health insurance of factory workers was set in called the ESI act. This was extended to the whole of India covering all industrial employees whose monthly salary does not exceed Rs. 3000/- per month.
Employees contribute 1.5% of their salaries.
Employer contributes 4% of the wage bill of the employees.
Grant from the state government.
Grant from the Government of India.

CENTRAL GOVEREMNT HEALTH SCHEME (CGHS)
This is scheme was established in 1954. Based on the principle of co-operative effort by the employees and the employer for their mutual benefits.

Benefits-
• Central government employees and families.
• Central Government pensioners.
• Member of Parliament.
• General public living in vicinity of CGHS dispensaries.

Services offered:-
Out patient services
Lab services
Domiciliary services.
In patient services
Specialist services.
Pediatrics like immunization Emergency
Family planning
Optical and dental aids.























FINANCE
IN
DENTAL CARE