CH5 Financing of Dental Care Flashcards
Historically, the financing of dental care was the responsibility of the _____ and the _______.
Historically, the financing of dental care was the responsibility of the patient and the dental provider.
The average expense for dental treatment is _____ per year
$384.00
What is the most common payment method in dental care delivery? It is based on a fee scale for all covered services and bills the patient for those services rendered.
Patients are treated and responsible for the fee (minus insurance if applicable).
Fee-for-service
Wich payment method for dental care does the dental office contract with a program to provide all or most dental services to the programs subscribers in return for payment on a per capita basis?
Patients with this usually have to pay a copay with each visit (HMOs, DMOs)
Capitation
Which dental care payment method utilizes trade for services, no cash exchanged?
Barter system
Which dental care payment method requires the patient to pay a fee at each visit, regardless of services rendered?
Encounter
What does UCR stand for; and what payment method does this occur with?
Usual, Customary, Reasonable
Fee-for-service
Usual, customary, & reasonable (UCR)
- Refers to the normal ______ set by your insurance carrier as reasonable for a service.
- May also be referred to as the ______ or “reasonable and customary” amount.
- Essentially is the insurance company’s allowed _______.
dollar amount, “allowed amount”, fee schedule
What type of dental insurance plan is made up of ‘not-for-profit’ organizations that negotiate fees for providing dental care?
These organizations are incorporated on a state-by-state basis and sponsored by a constituent dental society to negotiate and administer programs.
Dental service corporations
Ex: Delta Dental Plans Association
What type of dental insurane plan consists of organizations that offer limited dental coverage as part of their hospital-surgical-medical policies?
Health service corporations
Ex: Blue Cross/Blue Shield
What type of dental insurance plan is made up of providers of dental benefits and third-party contractors that collaborate with employer to offer services to employer’s employees at reduced prices?
Preferred provider organizations (PPO)
EX: Aetna U.S. Healthcare Dental
In which type of dental insurance plan are legal entities organized for dental providers to enter into contracts collectively to provide prepaid dental services to enrolled groups?
Hint: Uses the capitation method
Individual practice associations (IPA)
Ex: MD Individual Practice Associates, Inc.
Which payment method offers per capita payment for a defined population provided by specific dental providers?
The payment made to provider regardless of use.
Capitation plan
Ex: Concordia Plus
Benefits of a ______ is the reduced cost for participants but these types of insuance payment methods are are more restrictive.
Hint: Primarily concerned with preventive care.
HMO (Health Mainenance Organization group)
In this type of insurance plan, the practitioner contracts with the ___ to provide dental care services for lower than average fees in order to attract patients seeking lower costs. Patients can choose the providers they wish.
This gives the dentist a competitve edge over nonparticipating practitioners.
PPO (Preferred provider organization)
What code is used for an evaluation to determine changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation.
D0120
(Periodic Oral Evaluation Established Patient)
What code is used for an evaluation limited to a specific oral health problem?
D0140
(Limited Oral Evaluation Problem Focused)
What code is used for a detailed comprehensive dental exam which may include oral cancer evaluation, periodontal assessment, dental charting and dental caries evaluations?
D0150
(Comprehensive Oral Evaluation New or Established Patient)
What type of govenmental grant is urestricted and does not specify how it i to be spent when given to the state and local governments?
Block grants
What is the amount that the insurance entity will pay for covered dental services described in its policy?
Benefit
What is the federal program created to cover medical care for children whose families have incomes too high to qualify for state medical assistance but cannot obtain private insurance?all states participate, but some do not cover dental care
Children Health Insurance Program (CHIP)
Entering procedures rendered and determining whether payment will be approved or denied
Claims processing
Plan that operates for a profit
Commercial insurance plan
Legal agreement between an insurance entity and a group or individual
Contract
Portion of the cost of each service a patient pays
Copayment
Amount an individual enrolled in an insurance plan must pay for covered services before the insurance entity begins paying
Deductible
Dental claim
Patient’s formal request for insurance payment for a dental procedure that was rendered
Standard dental document used to file a claim or request authorization for a procedure
Dental claim form
Service provided by a dental provider that has been determined as a generally acceptable dental practice for a specific diagnosis and treatment
Dental necessity
Service for persons under twenty-one years of age for medical, dental, and vision care paid for by Medicaid
Early and periodic screening, diagnosis and treatment (EPSDT)
Contract between dental care providers and an employer (which eliminates the third party) stating the negotiated fees for services offered to the employer’s employees
Exclusive provider arrangement (EPA)
Form sent to the patient and provider explaining the approval or denial of payment for procedures rendered
Explanation of benefits
Form a dental practice uses to detail the services rendered a patient
Fee slip
Integration of health care delivery and financing
Managed care
Federal program that distributes funds to states for health care services provided to certain groups including aged, blind, and disabled people; those with low incomes; and certain members of families with dependent children
Medicaid (Title XIX)
Federal insurance program supported by a trust fund; provides limited funding for medically necessary dental services, such as oral/maxillofacial needs related to a medical condition for all people sixty-five years of age and older
Medicare (Title XVIII)
Medical condition that exists prior to the person’s coverage by an insurance entity.
Preexisting condition
Amount a group or an individual pays to the insurance entity for coverage
Premium
Large group of dental providers contracted to provide services to groups of patients
Prepaid group practice
Identification given to a specific procedure as designated in the Codes on Dental Procedures and Nomenclature published by the ADA
Procedure number
Legally licensed dental hygienist or dentist operating within a scope of practice
Provider
Specific procedure designated by a specific code
Single procedure
Either primary or permanent teeth that have adequate hard and soft tissue support
Sound natural teeth
Program in which a dental provider renders the service for which the patient’s sponsor (insurance company or employer) pays
Three-party system
Health care program serving active-duty service members, National Guard and Reserve members, retirees, their families, survivors, and certain former spouses worldwide; formerly known as Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
TRICARE
Program in which a dental provider renders the service for which the patient pays
Two-party system
A federal program that was created by the federal government to cover children from families that have incomes too high to qualify for state medical assistance but cannot obtain private insurance.
State Children Health Insurance Program (SCHIP)
All states participate, but some do not cover dental.
State Children Health Insurance Program (SCHIP)
What does ‘usual’ imply in regards to the USR?
it implies that the fee is what is most often charged by dental providers for a given dental service.
What does ‘customary’ refer to in regard to UCR?
it refers to a schedule of maximum fees charged by dental providers with similar training and service within a specific and limited geographic area as determined by the administrator of a dental plan based on submitted fees.
What does ‘reasonable’ refer to in regards to UCR?
it indicates that the fee meets the ‘usual’ and ‘customary’ definitions and is therefore justifiable.
An upward adjustment of the natural fluoride level in a community’s water supply to a level optimal for dental health is called _____.
fluoridation
Most often implemented at the local level through administrative action or a public vote by the _______.
City Council
The government share of expenses for dental care is ___%.
These funds go to programs that provide research, disease prevention, and control such as “swish and spit” and dental sealants in schools.
4%
