PPO Dental Insurance at a Glance

Most health insurance plans in the U.S. are either managed by a healthcare maintenance organization (HMO) or a preferred provider organization (PPO). Many healthcare practitioners prefer PPO over HMO due to its suitability in terms of coverage. As you know, dental insurance works differently from other types of insurance since most, if not all, of the dental problems can be prevented and treated with less cost. In exchange for PPO insurance, however, the dentist now becomes a “preferred provider.”

Consumers still have the choice of whether or not to go to a preferred provider, but the cost will be higher in a non-preferred provider. PPOs are also simple; unlike HMOs, PPOs don't need any referrals, let alone a primary care provider, for the plan to take effect. This translates to more patients for a dentist as he can treat patients regardless of referrals. With HMOs, however, patients need proof of referral before the dentist can treat them.

In PPOs, preventive dental care coverage ranges between 80 and 100 percent, basic care at around 80 percent, and major dental work (e.g. implants, crowns) at 50 percent. For a regular check-up worth $50, the patient may only need to pay no more than $10. The rest of the cost is shouldered by the PPO. It's safe to say that patients who regularly practice proper oral hygiene get to pay less for dental care.

Renegotiating Dental Insurance Fees

Getting the perfect insurance fee schedule is certainly the ideal scenario, but it’s also rarely the case. However, what many dentists like you don't realize is that it's never too late for your office to re-evaluate its insurance contracts and renegotiate its fee schedule. Renegotiation can be beneficial—not to mention profitable—to your practice, and it's not as difficult as you might think.

Start by asking some important questions about the insurance companies your office is contracted with, such as: “When did you last negotiate the fee schedule?” It is recommended that you renegotiate for a new fee schedule annually. This will give your office a chance to receive a more substantial reimbursement for common procedures. That said, keep in mind that you can renegotiate anytime you feel your current reimbursement is inadequate.

When you renegotiate, two things will ensure a more favorable fee schedule. One is if there's not a lot of competition in your area, and the other is if you have a good relationship with the insurance company you're contracted with. In both cases, these companies will be willing to participate in the fee negotiation process.

In the end, a firm understanding of how insurance companies work and knowing what you want out of them will give you a solid foundation for renegotiation. It may seem complicated at first, but it is something that your office should do and can benefit from.

Why Some Dentists Hesitate to Raise Their Fees

Like most other services, the cost of dental procedures rise periodically. However, quite a number of dentists are reluctant to raise their service fees perhaps for fear of losing their loyal clients. Although most dental offices review their pricing strategy on an annual basis, not too many of them increase their rates as often as they conduct reviews.

Some dentists do not see the point of raising their fees because it is the dental insurance companies that dictate the reimbursement rates. Still a lot of others wait for the economy to stabilize before deciding on the final figures for rate hikes that are long overdue. Not a few dental offices also choose to minimize the discounts they offer clients rather than charge higher rates.

Regardless of the actual pricing strategy each dental practice decides to adopt, it is crucial to ensure optimum PPO reimbursement rates and thereby remain profitable. Dentists who cater to individuals, families, and corporate clients covered by insurance should thus find ways to seek the highest compensation possible. Among other things, this may require the services of capable third-party providers who can negotiate with insurance companies and obtain maximum reimbursement rates on behalf of the dental office.

Preferred Provider Organizations (PPOs)

If you're an employee working for a company of good standing, you've probably heard of the term “PPO” that's usually discussed along with the many health benefits provided by your employer. PPO stands for Preferred Provider Organization, which is actually a health plan contracting a network of medical service providers available in case you need some tuning up. Referrals and primary care physicians are no longer required to approach PPOs.

Depending on your customized health plan, you might have to shoulder annual deductibles and co-payments upon visiting a member of your company's PPO. However, opting to stick to your family doctor or a medical specialist not in the preferred network will mean more deductions to your health privileges. Going out-of-network means you'll have to pay the doctor directly and file a claim with the PPO for reimbursements.

Health insurances also come in the form of HMOs. You shouldn't confuse PPO with HMO, or Health Maintenance Organization. Unlike PPOs, HMOs do not give reimbursements to employees who consult with doctors outside of the network. HMOs also require a referral from your primary care physician to see a specialist and have your medical expenses covered. Filing a claim with the HMO beforehand is also necessary to receive payment from your company.

PPO is just one of the many words you'll encounter concerning health benefits. Don't just sign agreements without reviewing their terms.

Dental Coverage by Class of Service

The amount of dental reimbursement a dentist receives usually depends on the type of service he or she has performed on the patient. This is known in dental plan terminology as “class of service,” which ranges from Class I to IV. The more extensive the dental treatment was, the less the coverage will be for the dentist. Class I pertains to diagnostic and preventive care. Regular checkups, cleanings, and dental x-rays are usually fully reimbursed.

Class II includes basic restoration; dental plans usually cover 80 percent of the cost of root canal and periodontal work. Class III involves advanced restoration procedures such as installing crowns and dental implants, and plans usually shoulder half of the cost. Finally, Class IV, which isn't a regular in dental plans, covers braces. The cost of orthodontic care is separate from a dentist's annual limit, but patients under 19 years of age may only be eligible for this type of reimbursement.

Keep in mind that most dental plans won't cover you for the whole year, as they usually set a number on the frequency of exams. They can only cover so many preventive care exams before dentists have to wait for next year for reimbursement. Dental plans also include time limits on certain services such as the replacement of prosthetics and orthodontics.