Monday, January 16, 2012

Dental Insurance - HMO or PPO

How does dental Insurance Work?

Understanding the HMO dental insurance plans from a dental office perspective allows you to make better informed decisions regarding your oral health.

If you are fortunate to have your employer offer dental insurance, it's a good idea to accept a dental plan that will help you maintain your oral health by at least getting a regular check up and cleaning.

If you have to purchase dental insurance on your own, it's crucial to understand the details involved in your plan and whether the premiums are worth what you will get back in benefits.

How does HMO work?
An HMO plan usually costs you less out of pocket upfront, but does it really cost less long term.  HMO dental insurance is generally a network of dentists that have agreed to participate in a particular plan.  How a dentist gets paid by HMO insurance is a monthly check received called a "capitation check".  The dentist will be paid anywhere between $5.00 and $20.00 for each patient that has picked his name out of the network book, regardless of whether the patient comes in or not, he does this in agreement that when you actually do come in, the dentist does not get paid for your routine visit (exam, cleaning), so guess what?, the dentist would rather you not come in. If you require a filling, all the dentist will collect is your visit co-pay, generally anywhere between $5.00 and $15.00.

HMO insurance is usually limited on coverage for the type products and treatments that a patient can receive, most do not cover white composite fillings, porcelain crowns, bridge, etc..., if you are in need of those treatments you must pay out of pocket above and beyond what they will cover, which is minimal.  PPO insurance on the other hand allows for many of these treatments and will pay a percentage towards those treatments, while you pay the difference.

Many reputable dentists have stopped accepting HMO insurance due to the variance in coverage and the treatment planning involved, many dentists I've spoken with have confirmed that they find it difficult to treat one patient different than the other based on their coverage, HMO tends to force them to do so.  One dentist told me "I don't want an insurance plan deciding the best course of treatment for my patient". 

You will notice that most dental offices accepting HMO insurance are usually larger and have more than one operating dentists.  HMO insurance does not pay the dental office much, most offices have to hire new graduating dentists and pay them a daily rate and commissions on treatments sold.  Many of the dentists I personally know started out working for these larger offices, all ended up quiting and opening their own practice due to the pressures involved in "selling dentistry". 

Since a dentist gets paid a minimal amount for fillings under an HMO plan, many of the employed dentists are asked to up sell a treatment, a large filling can easily be turned into a crown.  Many treatments that can be done on the same day are turned into multiple visits which allows the dental office to collect your visit co-pay multiple times.  It's too much selling involved, therefore you find many of the private family owned, single dentist operated offices no longer accept HMO insurance. 

If HMO seems to be the more affordable solution for you, do your homework, the best person to ask is your dentist.  In my opinion, if you have excellent oral hygiene, no gum disease issues or your mouth isn't susceptible to cavities, it's not a bad idea to have any dental insurance plan for your routine diagnostic and preventative visits. 

If your teeth require a lot more treatments such crowns, bridges, partials, dentures.  It's probably more affordable in the long run to look at a PPO plan that allows for these types of treatments.  PPO plans cost more but at least you will know you're receiving the treatment you need because the dentist has no reason to up sell anything, they get paid for the work they do.  Having said that, the most important step you can take in all of this is know how to choose a good dentist, have a good understanding of what your dental insurance covers and you will be on your way to making the informed decision on the best dental insurance whether it's HMO or PPO.

No comments:

Post a Comment