Chapter 18 Flashcards
What is the most important element for creating a cost-effective and relatively problem free dental plan?
Plan design
What are well-designed dental plans configured to do?
Ensure the efficient allocation of benefit dollars by creating incentives for patients and providers to maintain oral health and treat dental disease
What are members free to do in passive PPOs?
Members are free to see any dentist they wish
Cost, utilization, and satisfaction among members and providers are greatly affected by how services are (evaluated and rated / classified and paid).
Classified and paid
Moving procedures between classes is known as __________.
Class shifting
Class shifting for diagnostic and preventive services is (less / more) common than other forms of class shifting
Less common
Why is class shifting most widespread for basic restorative services?
The restorative services category is more complex and useful in terms of class-shifting opportunities, plus the potential for cost savings is greater.
Why is it especially important to know how non-network providers will be reimbursed under a passive PPO plan?
Non-network reimbursement is a primary tool for encouraging greater use of network dentists and holding beneficiaries financially accountable for going out of network.
From the plan perspective, what is the impact of non-network reimbursement approaches?
Can affect cost, the plan’s reputation with providers, and network stability.
What is the impact of non-network reimbursement on purchasers?
Affects cost and member satisfaction
Payments to non-network dentists are based on the lesser of the_________ or the __________.
Dentist’s charge / PPO fee schedule
To collect the difference in their fee and what the plan pays, in most cases dentists are allowed to __________.
Balance bill
What metric is a usual, customary and reasonable (UCR) fee based on?
A specific percentile level determined by the administrator
A separate fee schedule used for reimbursement to non-network dentists is called __________.
Maximum allowable charge or MAC schedule
Along with the rapid growth in the number of enrollees and percent of market share, how else are PPOs changing today?
Many purchasers are switching from passive to active PPOs
Active PPOs provide (greater / lesser) options for controlling cost and benefit design.
Greater options
Which feature of active PPOs provides greater steerage to lower cost network dentists?
Benefit differentials between in- and out-of-network care.
When designing or recommending a particular plan design and network, what is it important to consider?
The unique characteristics of the purchaser and group
Changing from a passive PPO to an active PPO can cause (disruption / interruption) for users of the current plan.
Disruption
What trade-offs will sponsors and members face in the switch to an active PPO?
Active PPOs involve trade-offs among cost, benefit value, and access to network dentists
What does the text suggest very cost-sensitive groups would be willing to accept as a trade-off for a more limited choice of dentists?
Better benefits at a lower price
When changing from a passive PPO to an active PPO, (small, locally clustered groups / large, widely dispersed groups) should have little problem with access issues
Small, locally clustered groups
Actuarial estimates of utilization and cost are highly dependent on __________.
Demographics
When budget constraints and price sensitivity are concerns for the sponsor and members, (passive PPOs / active PPOs) are especially effective for controlling cost.
Active PPOs
