Chapter 19 Flashcards
What are three alternative names for dental HMOs?
DHMOs, prepaid dental plans, and dental capitation plans
How are dentists paid under DHMOs?
Dentists are paid a capitation or on a per capita basis
How is payment from administrators made for services rendered?
Payment is rendered via a fixed monthly amount “per family” or “per person” regardless of the services rendered.
In a DHMO, enrollees must see a network provider to obtain benefits. What is this type of arrangement called?
A “closed panel” network.
What was an unintended consequence of transferring financial risk to providers?
It encouraged dentists to use various rationing methods
How have administrators been required to address the rationing concern?
Administrators must monitor utilization and appointment wait times
Today, reimbursement to the provider is typically in the form of (monthly capitation payments / patient copayments / a combination of both).
A combination of monthly capitation payments and patient copayments.
True or False: Under DHMO plans, low-cost, high frequency services may be fully capitated with no patient copayment, while higher-cost, lower-frequency services may carry increasingly high
copayments.
True
What is the purpose of the encounter form filing fee?
A nominal sum administrators pay providers to encourage submission of encounter data (e.g., information regarding services performed per patient treated) to capture actual utilization.
How have administrators responded to patients needing extensive dental services that cannot be covered by the small monthly capitation amount?
Through minimum financial thresholds for providers performing a higher level of major services.
What are the advantages of the hybrid model of reimbursement?
Allows easy implementation (through the merger of DHMO reimbursement methods with varying copayment schedules) and encourages dentists to participate.
How is payment handled under the hybrid arrangement?
By a combination of patient copayments and additional supplements by the administrator.
The financial mechanism where the administrator pays the difference between a minimum amount and any patient copayment is called __________.
As a supplemental payment
With the increasing growth of large group practices, how are referrals handled?
Many plans have delegated the referral approval to the primary care dental office.
True or False: Group practices that refer a certain number of patients to specialists each month are paid a capitated referral fee.
False
True or False: Preventive services and early treatment have proven to be highly cost effective in dentistry.
True
What did the author of the first edition of this text, published in 1993, predict about DHMO growth?
That enrollment in DHMOs would ultimately grow to be 20 to 25 percent of the market.
When and at what percentage of market share did DHMOs peak?
In 1998 at approximately 19 percent of market share.
By 2010, DHMO market share had fallen to (8 percent / 10 percent) of total dental plan enrollment.
8 percent.
Initially, purchasers liked the concept of DHMOs but only focused on __________ and__________.
Premium and sometimes the geographic coverage of the network.
What did many employers hope to achieve when they shifted their focus to preferred provider organizations (PPOs)?
That this alternative would offer the best of both worlds—managed care and greater access to care.
True or False: The growth in medical and dental PPOs was at the expense of traditional fee-for-service/indemnity plans.
True
Why are so many employee/member beneficiaries willing to join PPOs?
Better benefits; modest savings for in-network care; freedom to choose the provider.
What unrealistic expectation did purchasers have for DHMOs?
Purchasers wanted an office on every corner.
