Chapter 17 Flashcards
(30 cards)
What is the definition of a dental preferred provider organization (PPO)?
A network of dentists created through a contractual agreement between a dental program administrator and providers, for the delivery of services to defined patient populations, where reimbursement is based on predetermined, discounted fees.
Dental PPOs are now the dominant dental delivery system with a market share of (74 / 94)
percent by enrollment.
74 percent of market share by
enrollment.
True or False: A condition that contracted PPO dentists do not have to abide by is peer review and oversight processes established by the administrator.
False
True or False: Contracted PPO dentists must agree to maintain certain standards of practice
and levels of malpractice insurance.
True
Dental PPOs far exceed enrollment in (indemnity / discount / DHMO / all three) type plans.
All three plans
What factors fueled PPO growth?
Increased demand from purchasers; increased dedication of carrier recruiting efforts; greater acceptance of PPOs among the dental community.
In 2010, about _____ percent of actively practicing dentists in the U.S. participated in at least
one PPO.
64 percent
In 2011, PPO providers participated in an average of 8.8 networks, an increase of _____
percent from the 2008 average of 5.9 percent.
49 percent
What are two notable trends initiated by administrators?
Administrators have (1) become more flexible in negotiating with providers and (2) increased the use of tiered networks.
True or False: The higher the fee schedule, the more dentists will be willing to participate and
the greater the size of the network.
True
In reviewing the section on PPO participation trends, several points relate to patient volume.
Identify those factors most likely to improve cash flow for PPO providers.
Steady cash flow; increased visibility; maintaining patient volume; new patient referrals; greater needs of new patients; elective services
Client base, geographic location of providers and customers, degree of market power
possessed by the providers and the administrator are all factors that need to be considered in
developing __________.
PPO fee schedules and the level of network discounts
What are PPO schedules based on?
Discounts off the community average and the average of submitted fees based on claims; a targeted percentile.
For large, national networks, a strategy considered financially sound, and often better for
recruiting efforts, is to have (more / less) fee schedule zones.
more
True or False: Due to today’s economic uncertainty, it has become quite uncommon for carriers
to negotiate unique fee schedules with individual providers.
false
Basic dental PPO plans have propagated a profusion of hybrid varieties, distinguished by the
way they affect __________.
Access and cost.
What are the two primary types of PPOs that dominate the market today?
Active and passive PPOs.
What is the key characteristic of a passive PPO?
The benefit design is the same irrespective of whether or not the patient goes to a participating dentist
True or False: Under a passive PPO agreement, participating dentists are not allowed to
“balance bill” any amount over and above the fee schedule for covered services.
True
Why were passive PPOs considered a transitional product in the dental market?
Passive PPOs were attractive to groups looking for a “gentle managed care step” in their dental program
What plan feature makes the passive PPO model popular and well received by participants
and purchasers?
Participants can go to any dentist they choose with no reduction in benefit design
Why were purchasers incentivized to migrate to active PPO plans?
The desire to contain costs motivated purchasers to steer patients to network dentists.
What is the key characteristic of an active PPO plan?
The benefit differential between in- and out-of-network care
What financial incentives help to steer participants to network dentists?
Lower participant coinsurance and deductibles and/or higher annual and lifetime maximums