1. Understand the differences between paid premium and self-funded dental plans
2. Compare and contrast the various types of managed care plans in the marketplace
3. Recognize the various types of plan designs that may present at your office
4. Understand the differences between Medicaid and Medicare dental coverage
5. Discuss various cost containment measures utilized by dental benefit plans
6. Identify the most common types of coordination of benefits
7. Describe several of the many payment challenges faced by out-of-network dentists

1. Relationships with Third-Parties
   1. Contractual
   2. Non-Contractual
   1. Failure to Recognize Assignment of Benefits
   2. Reduced Levels of Reimbursement
   3. Higher Deductibles and Lower Annual Maximums
   4. Failure to Receive Explanation of Benefits Statements
   5. Faster Payment for Out-of-Network Dentists Allowing Discounts
2. Types of Dental Plans
   1. Preferred Provider Organizations (PPO)
   2. Dental Health Maintenance Organizations (DHMO)/Capitation Plans/Prepaid Plans
   3. Indemnity Plans
   4. Direct Reimbursement (DR®)
   5. Point of Service Plans
   6. Discount or Referral Plans
   7. Exclusive Provider Organizations (EPO)
   8. Table or Schedule of Allowances Plans
3. Financing of Dental Plans
   1. Self-Funded Plans
   2. Paid Premium Plans
   3. Medicaid
   4. Medicare
   5. Medicare Advantage Plans
4. Management of Dental Plans
   1. Insurance Companies
   2. Third-Party Administrators (TPA)
5. Plan Designs
   1. Traditional
   2. Dollar-Based
   3. Preventive Only/Limited Benefit
   4. Cafeteria Plans/Section 125 Plans
   5. Health Savings Accounts (HSA)
   6. Health Reimbursement Arrangements (HRA)
   7. Flexible Spending Accounts (FSA)
6. Typical Plan Benefits and Limitations
   1. Pre-existing Conditions
   2. UCR – Three Different Concepts, Not One
   3. Annual Maximums
   4. Managed Care Cost Containment Features
   1. Least Expensive Alternative Treatment Provisions (LEAT)
   2. Bundling of Dental Procedures
   3. Downcoding
   4. Predetermination
   5. Deductibles
   6. Coinsurance Provisions
7. Coordination of Benefits (COB)
   1. Types of COB
      1. Traditional
      2. Non-Duplication of Benefits
      3. Maintenance of Benefits
      4. Carve Out of Benefits
      5. Integration of Benefits
   2. Dependents
   3. When Does Secondary Pay?
   4. ADA Guidelines on Coordination of Benefits for Group Dental Plans
8. How to Receive Assistance
   1. Claims Appeals
   2. State Insurance Commissioner’s Office
   3. Department of Labor
   4. Patient’s Human Resources Department
   5. Your American Dental Association

1.  “What Every Dentist Should Know Before Signing a Dental Provider Contract”, American Dental Association
2. ADA’s Understanding Your Dental Benefits, 2009, page 4.
3. Accessed from http://www.cms.hhs.gov/MedicaidDentalCoverage/, September 23, 2009
4. Accessed from http://www.cms.hhs.gov/MedicareDentalCoverage/, September 23, 2009
5. Accessed from http://www.medicare.gov/choices/advantage.asp, January 11, 2010
6. Accessed from http://www.irs.gov/govt/fslg/article/0,,id=112720,00.html#1, September 16, 2009
7. Accessed from http://www.ustreas.gov/offices/public-affairs/hsa/faq_basics.shtml, September 29, 2009
8. Accessed from http://en.wikipedia.org/wiki/Flexible_spending_account, September 23, 2009
9. ADA News, ADA/NADP share views on bundling and downcoding, June 20, 2007

Published date 2010-2013