Chapter 17 Flashcards

(30 cards)

1
Q

What is the definition of a dental preferred provider organization (PPO)?

A

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.

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2
Q

Dental PPOs are now the dominant dental delivery system with a market share of (74 / 94)
percent by enrollment.

A

74 percent of market share by
enrollment.

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3
Q

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.

A

False

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4
Q

True or False: Contracted PPO dentists must agree to maintain certain standards of practice
and levels of malpractice insurance.

A

True

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5
Q

Dental PPOs far exceed enrollment in (indemnity / discount / DHMO / all three) type plans.

A

All three plans

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6
Q

What factors fueled PPO growth?

A

Increased demand from purchasers; increased dedication of carrier recruiting efforts; greater acceptance of PPOs among the dental community.

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7
Q

In 2010, about _____ percent of actively practicing dentists in the U.S. participated in at least
one PPO.

A

64 percent

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8
Q

In 2011, PPO providers participated in an average of 8.8 networks, an increase of _____
percent from the 2008 average of 5.9 percent.

A

49 percent

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9
Q

What are two notable trends initiated by administrators?

A

Administrators have (1) become more flexible in negotiating with providers and (2) increased the use of tiered networks.

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10
Q

True or False: The higher the fee schedule, the more dentists will be willing to participate and
the greater the size of the network.

A

True

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11
Q

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.

A

Steady cash flow; increased visibility; maintaining patient volume; new patient referrals; greater needs of new patients; elective services

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12
Q

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 __________.

A

PPO fee schedules and the level of network discounts

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13
Q

What are PPO schedules based on?

A

Discounts off the community average and the average of submitted fees based on claims; a targeted percentile.

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14
Q

For large, national networks, a strategy considered financially sound, and often better for
recruiting efforts, is to have (more / less) fee schedule zones.

A

more

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15
Q

True or False: Due to today’s economic uncertainty, it has become quite uncommon for carriers
to negotiate unique fee schedules with individual providers.

A

false

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16
Q

Basic dental PPO plans have propagated a profusion of hybrid varieties, distinguished by the
way they affect __________.

A

Access and cost.

17
Q

What are the two primary types of PPOs that dominate the market today?

A

Active and passive PPOs.

18
Q

What is the key characteristic of a passive PPO?

A

The benefit design is the same irrespective of whether or not the patient goes to a participating dentist

19
Q

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.

20
Q

Why were passive PPOs considered a transitional product in the dental market?

A

Passive PPOs were attractive to groups looking for a “gentle managed care step” in their dental program

21
Q

What plan feature makes the passive PPO model popular and well received by participants
and purchasers?

A

Participants can go to any dentist they choose with no reduction in benefit design

22
Q

Why were purchasers incentivized to migrate to active PPO plans?

A

The desire to contain costs motivated purchasers to steer patients to network dentists.

23
Q

What is the key characteristic of an active PPO plan?

A

The benefit differential between in- and out-of-network care

24
Q

What financial incentives help to steer participants to network dentists?

A

Lower participant coinsurance and deductibles and/or higher annual and lifetime maximums

25
Why do many plan sponsors, dentists, and patients view the active PPO as a win-win scenario?
Sponsors can offer richer benefits at an affordable price; network dentists increase traffic and patient loyalty; patients get more for their benefit dollar
26
What pushes patients away from seeking treatment from out-of-network dentists?
Reduced benefits and (possibly) higher fees
27
True or False: In an exclusive provider organization (EPO) plan patients have access to benefits when they seek care from a dentist not in the network.
False
28
EPOs are created for which segment of the dental market?
A particular employer with a large or highly concentrated employee population
29
What is the most distinguishing feature of a POS plan?
Members do not have to choose any particular dentist or network during annual open enrollment. They are free to switch at will with benefits available at point of service.
30
The most common POS dental benefits program combines design features of __________ and __________.
PPOs and DHMOs