With escalating costs of dental supplies and malpractice insurance premiums, costs for dental services have gone up, with corresponding increases in dental insurance premiums. Dental insurance carriers have developed a variety of plans to accommodate dentists, employers and patients' financial situations and dental needs. One of the plans they offer is the Preferred Provider Organization (PPO).
Preferred Provider Organization (PPO)
A Preferred Provider Organization consists of dentists who have agreed to accept reimbursement for dental services according to the benefit amount indicated in the plan's schedule of benefits. The reimbursement provided by the insurance plan may be lower than the individual dentist typically charges for services rendered, but the dentist benefits from additional income based upon an increase in patient volume.
Participating Dentists
Patients enrolled in PPO plans must use network dentists to receive full plan reimbursement for dental services rendered. Dentists located within the confines of the insurance plan's geographical coverage area are invited to participate. They must provide copies of licenses, malpractice insurance coverage, office hours, emergency contact information for patients, waiting time for appointments, number of treatment rooms, number of staff members and any other pertinent information required by the insurance company. They will also be required to sign a contract agreeing to conditions of participation. Patients using out-of-network dentists will be responsible for paying the treating dentist's fee. If a plan benefit is available, it will be less than that paid to an in-network dentist.
Schedule of Benefits
A system of codes is used to identify individual dental procedures, similar to the codes used for services rendered by medical providers. The PPO plan benefit for each procedure is based upon the reasonable and customary charges for services performed by dentists in the region in which the dental office is located. The insurance benefit amount for these procedures may be set at a percentage of the reasonable and customary charges, but it is usually based upon a lower amount fixed by the insurance carrier and listed in the plan's schedule of benefits.
Deductibles and Maximums
Some PPO plans have a deductible that is charged to the patient before insurance reimbursement is made to the dentist for restorative and major services. Fillings fall under the category of restorative services; prosthetics such as bridges and dentures are considered major services. After the patient has paid the deductible, the plan will begin reimbursement to the dentist for each service rendered up to the maximum benefit amount indicated in the schedule of benefits. A deductible does not generally apply to preventive services, which include X-rays, examination and routine cleaning. These services are usually covered at 100 percent of the plan's benefit allowance, but, as with all benefits, they may be subject to annual maximums. If the plan has a fixed annual maximum, benefits will continue to be paid until the maximum has been reached.
Co-Insurance and Non-Covered Services
A co-insurance may apply to restorative and major services rendered: if the plan pays 80 percent of the scheduled benefit for these services, the remaining 20 percent is considered co-insurance. For example, a filling that is covered up to a maximum charge of $100.00 will be eligible for an insurance reimbursement of $80.00 (80%); the $20.00 (20%) balance is the co-insurance portion of the charge and is to be paid by the patient.
Non-covered services are determined by the insurance carrier and include any service not listed in the schedule of benefits. The patient assumes full financial responsibility for payment of these services that are usually charged according to the treating dentist's regular fee schedule.
Tags: services rendered, based upon, benefit amount, dental services, major services, plan benefit