Chapter 19

Question 1

What are three alternative names for dental HMOs?

Answer 1

DHMOs, prepaid dental plans, and dental capitation plans

Question 2

How are dentists paid under DHMOs?

Answer 2

Dentists are paid a capitation or on a per capita basis

Question 3

How is payment from administrators made for services rendered?

Answer 3

Payment is rendered via a fixed monthly amount “per family” or “per person” regardless of the services rendered.

Question 4

In a DHMO, enrollees must see a network provider to obtain benefits. What is this type of arrangement called?

Answer 4

A “closed panel” network.

Question 5

What was an unintended consequence of transferring financial risk to providers?

Answer 5

It encouraged dentists to use various rationing methods

Question 6

How have administrators been required to address the rationing concern?

Answer 6

Administrators must monitor utilization and appointment wait times

Question 7

Today, reimbursement to the provider is typically in the form of (monthly capitation payments / patient copayments / a combination of both).

Answer 7

A combination of monthly capitation payments and patient copayments.

Question 8

True or False: Under DHMO plans, low-cost, high frequency services may be fully capitated with no patient copayment, while higher-cost, lower-frequency services may carry increasingly high
copayments.

Answer 8

True

Question 9

What is the purpose of the encounter form filing fee?

Answer 9

A nominal sum administrators pay providers to encourage submission of encounter data (e.g., information regarding services performed per patient treated) to capture actual utilization.

Question 10

How have administrators responded to patients needing extensive dental services that cannot be covered by the small monthly capitation amount?

Answer 10

Through minimum financial thresholds for providers performing a higher level of major services.

Question 11

What are the advantages of the hybrid model of reimbursement?

Answer 11

Allows easy implementation (through the merger of DHMO reimbursement methods with varying copayment schedules) and encourages dentists to participate.

Question 12

How is payment handled under the hybrid arrangement?

Answer 12

By a combination of patient copayments and additional supplements by the administrator.

Question 13

The financial mechanism where the administrator pays the difference between a minimum amount and any patient copayment is called __________.

Answer 13

As a supplemental payment

Question 14

With the increasing growth of large group practices, how are referrals handled?

Answer 14

Many plans have delegated the referral approval to the primary care dental office.

Question 15

True or False: Group practices that refer a certain number of patients to specialists each month are paid a capitated referral fee.

Answer 15

False

Question 16

True or False: Preventive services and early treatment have proven to be highly cost effective in dentistry.

Answer 16

True

Question 17

What did the author of the first edition of this text, published in 1993, predict about DHMO growth?

Answer 17

That enrollment in DHMOs would ultimately grow to be 20 to 25 percent of the market.

Question 18

When and at what percentage of market share did DHMOs peak?

Answer 18

In 1998 at approximately 19 percent of market share.

Question 19

By 2010, DHMO market share had fallen to (8 percent / 10 percent) of total dental plan enrollment.

Answer 19

8 percent.

Question 20

Initially, purchasers liked the concept of DHMOs but only focused on __________ and__________.

Answer 20

Premium and sometimes the geographic coverage of the network.

Question 21

What did many employers hope to achieve when they shifted their focus to preferred provider organizations (PPOs)?

Answer 21

That this alternative would offer the best of both worlds—managed care and greater access to care.

Question 22

True or False: The growth in medical and dental PPOs was at the expense of traditional fee-for-service/indemnity plans.

Answer 22

True

Question 23

Why are so many employee/member beneficiaries willing to join PPOs?

Answer 23

Better benefits; modest savings for in-network care; freedom to choose the provider.

Question 24

What unrealistic expectation did purchasers have for DHMOs?

Answer 24

Purchasers wanted an office on every corner.

Question 25

What expectations did DHMO patients have?

Answer 25

Their dentist in the network and DHMOs that functioned like medical HMOs.

Question 26

True or False: By design, DHMOs must have fewer offices to give providers sufficient patient volume to be profitable.

Answer 26

True

Question 27

At least (200 / 300 / 400) members are needed in each dental office for the monthly total capitation to cover the cost of the services provided these members.

Answer 27

200 members

Question 28

Why is DHMO penetration unlikely in less populated areas?

Answer 28

It is difficult to find dentists willing to participate

Question 29

How did poor employee communications contribute to misconceptions about DHMOs?

Answer 29

Without understanding the trade-offs, employees wanted to pay less and get more.

Question 30

True or False: Premium cost savings of 20 percent was not worth the employee dissatisfaction that resulted with some DHMOs.

Answer 30

True

Question 31

Despite the growing pains, it appears that DHMOs continue to be a (best-buy / viable option) for dental benefits.

Answer 31

Viable option

Question 32

When employees in a large group situation are given a choice between a PPO or indemnity plan and a DHMO, what has industry experience shown?

Answer 32

Between 15 and 25 percent of the employee group will select the DHMO

Question 33

True or False: A well-designed DHMO has the potential to provide a more efficient mix of services at less cost than a fee-for-service dental plan.

Answer 33

True

Question 34

Under (PPO / DHMO) reimbursement models, dentists are financially incentivized to help patients maintain their oral health.

Answer 34

DHMO

Question 35

Under fee-for-service reimbursement, dentists are incentivized to provide treatment options offering the (highest profit margin / least invasive approach).

Answer 35

Highest profit margin

Question 36

With restructuring of DHMO plans, what can participating dentists hope to realize?

Answer 36

An adequate profit

Question 37

What have today’s more sophisticated data reporting mechanisms helped to achieve?

Answer 37

Better underwriting practices that can work for DHMO plan sponsors, patients, and dentists.

Question 38

How has the risk to primary dentists been addressed under restructured plans?

Answer 38

Reimburses specialists on a fee-for-service basis.

Question 39

Many newer DHMO models provide (a floor for reimbursement / fee-for-service supplements / both).

Answer 39

Both a floor for reimbursement or fee-for-service supplements

Question 40

Larger, more sophisticated DHMO administrative structures will lead to __________.

Answer 40

Economies of scale.