Posted October 24, 2016
With the focus on medical benefits, employers and producers may spend less time looking at dental plan details. It may seem like Participating Provider Organization (PPO) dental plans are all pretty much the same. But check the details.
While dentists may have an agreement with more than one dental carrier, the structure and coverage levels in each network may be different. Frequently people make decisions solely on price without fully understanding each carrier’s differences, including the process for calculating payments and reimbursing claims. Review the dental contract to understand network design and determine whether the plan will meet customer needs.
Dental Network Design
When setting up a PPO network, dental insurance carriers contract with dental offices in each market and negotiate discounts. These discounts can be as little as 10 percent or as much as 40 percent, depending on the dental offices in that market, and the number willing to agree to the fees being offered by the carrier.
Generally plan members using dentists in the network will incur out-of-pocket costs only for coinsurance or noncovered procedures depending on their plan design. While employees with a PPO dental plan may visit any dentist, they could experience higher out-of-pocket costs with dentists who are not in the network.
PPO Plan Differences
Look for plan differences in PPO network size and administration of benefits, payment structure, claims processing and customer service support. Consider these suggestions for spotting the differences:
- Evaluate the network organization and size. When reviewing the network included with the plan, consider the number of dentists available to employees. The network size should be large enough to meet the needs of employees and their families. It helps to have at least two dental offices in the network within five or 10 miles of the employer’s offices.
- Verify the frequency of updates. Insurance carriers should revise network directories regularly. It’s frustrating for employees to contact dentists only to find they are no longer at that location or participating in a network.
- Consider whether dentist credentials are verified regularly. The carrier should consistently check dentist and office credentials to ensure records are accurate, certificates are current, and there is regular participation in educational training programs.
- Compare the fee structures for procedures. Since most carriers have the ability to increase or decrease their costs by changing benefit levels, procedure placements and reimbursement levels can be hard to determine. It pays to compare plans carefully.
- Work with a knowledgeable insurance carrier. The insurance carrier sales representative should be an excellent resource for producers and employees, providing information on trends, plan features and coverage levels, explaining industry issues, and making recommendations on changes that would improve the quality or cost efficiency of the plan. If your sales representative just shows up at renewal time, you may not be receiving the service you really need.