Professional Documents
Culture Documents
Presented
by:
S.M.M.Hussa
CONTENT
INTRODUCTION
INTRODUCTION
Health care services traditionally have been provided on
fee-for-service basis whereby the patient receives
specific services and pays the provider for service
directly
As the costs of health care continues to rise, the
majority of the people cannot afford dental treatment,
especially when it is provided on a fee-for-service basis
Methods have to be sought to ease costs either by
legislature or by development of a variety of funding
approaches
Dental personals owe it to themselves and to their
patients to develop the clearest possible understanding
of the social forces at work in this complex situation.
PRIVATE FEE-FOR-SERVICE
The two party arrangement is the
traditional form of reimbursement
for dental services
Dentists overwhelmingly prefer to
practice under this arrangement and
this is considered as the most
efficient way of providing dental care
Fee-for-service care is an integral
part of private practice
PRIVATE FEE-FOR-SERVICE(cont)
Advantages
1. It is culturally acceptable
2. This system is flexible-fees can be changed in
accordance with market conditions & dentist
is also able to practice price discrimination
3. It is administratively simple- since dentist
need not keep a written list of fees for
procedure
4. It is only system under which some form of
dental care likely will ever be provided
1. Deductible:
. It is stipulated flat sum that patient
must pay toward the cost of
treatment before the benefits of
program go into effect
. Some time called front end payment
Reimbursement of dentist in
prepayment plans
The ADA has consistently supported the
concept of Usual, Customary , and
Reasonable (UCR) fee as the preferred
method for reimbursement for dentist in
prepayment plans
Apart from UCR fees the other only form
offer is the table allowances
Usual Fee: the fee usually charged for a
given service by an individual dentist to
private patient i.e his or her usual fee
Reimbursement of dentist in
prepayment plans
Customary fee: a fee is customary when it
is in range of usual fee charged by dentist
of similar training and experience for the
same service within the specific and
limited geographic area
Reasonable fee: a fee is reasonable if it
meets the above 2 criteria or it is
justifiable considering the special
circumstances or particular patient in
question
Reimbursement of dentist in
prepayment plans
A table of allowances:
Is defined as list of covered services that
assigns to each service a sum that
represents the total obligation of plan with
respect to payment for such service but
that does not necessarily represent dentist
full fee for that service
If the fee become more than that assigned
to that service by the carrier the remainder
will b collected by dentist from patient
Commercial insurance
Characteristics:
They can be more selective
Claim no obligations towards dental health of
community
Provides specific cash payment
reimbursement for specified covered services
Organize their levels of reimbursement
differently
Do not conduct fee audit and post treatment
dental examination
Commercial insurance
They can compete successfully
because their expertise in promotion
and marketing allows them to
present attractive total health
package plans to potential
purchasers
In India Commercial insurance now
started providing insurance for
dental procedures which do not
require hospitalization
Staff model
Group model
Independent practicing association
Direct contract model
1. Staff model
. in this employees are salaried by
HMO
. May or may not be a dental director
2. Group model
HMO contracts directly with group
practice , partnership , or corporation
for provision of dental service
Caption plans
The basis of capitation plan is that the
contracting provider whether an HMO group
practice or individual dentist receives an
established negotiable amount monthly or
annually basis for each eligible patient
The money is paid regardless patient
utilizes care or not
In return patient is entitled to receive a
prescribed set of service over a specific
period
Salary
Dentists in some group practices, those in the
armed forces and those employed by public
agencies are salaried
Advantages
It allows a dentist to be largely free of business
concerns of running a practice thereby allowing
the dentist to concentrate on clinical matters
Fringe benefits are also often attractive
Disadvantages
There could be a lack of financial incentive that
some dentist needs to be highly productive
Public programs
Private practice is usually not able to
meet dental demands of all the public
Therefore a number of public program
are aim to meet the need of specific
groups in diverse society
Public financing of dental care:
A. Medicare
B. Medicaid
C. National health insurance
Public programs
Medicare:
o This program removed all financial
barriers from hospital and physician
service for all persons ages 65 and
above regardless of financial means
o By the mid-1970s Medicare has two
parts
Part A:hospital insurance
Part B:supplimental medical
insurance
Public programs
Medicaid:
It is a joint federal state program covering at
least these basic services
o Inpatient hospital care
o Outpatient hospital care
o Laboratory and x-ray service
o Skilled nursing facility services
o home health services for individual aged
under 21&older
o Physician services
Public programs
National Health Insurance
Introduced by Bismarck in Germany
Primarily a financing mechanism by
which health care service are paid
from publicly organized fund
Humanitarianism was a factor in their
development
Conclusion
The financing of dental care is well developed
and well practiced in developed countries like
U.S
However in India fee for service is still most the
prevalent form of availing dental services
Although free dental services are provided by
the government at some of the health centers,
it is scarce and in-efficient
Dental insurance is in its infancy in which the
very high premiums , dental service is still very
far from the reaches of indigent.
Thank you