Dental Insurance

PPO Networks with No Surprises
by Karen M. Gustin, LLIF

Dental insurance is a high-demand benefit, making it a staple in employee benefit packages across the United States. Most employees have high expectations of their dental benefits. They want quality care and they want the insurance to pay their claims quickly and efficiently.

Employees tend to be rather finicky about dentists. They want the freedom to see the dentist of their choice and pref-erably someone who is not too far from where they live or work. Employees tend to stick with the dentist with whom they feel comfortable.

Not surprisingly, employees prefer having PPO networks incorporated into dental benefit plans. PPO networks are designed to give employees access to the dentists of their choice at contracted prices. Many employers and employees think PPOs are standardized programs that are administered similarly by all dental insurance carriers. But, PPOs are not designed the same across the dental insurance industry.
Each carrier has different strengths, capabilities, and philosophies about dental care and operational strategies. These differences affect the design of dental plans, coverage amounts, and the structure of PPO networks.

You have an important role in helping employers and employees evaluate PPO networks, dental care options, and plan designs. When comparing PPOs, a top factor to consider is the financial impact on the employer and employees. Employee satisfaction is another top factor to consider.

As you compare PPOs, you will notice that dental carriers tend to tout the size of their networks. However, a bigger number does not always mean that employees will have access to the dentists of their choice.

Not all carriers use the same methods to count PPO dental providers. Understanding the following terminology and asking carriers how they count their network dentists will help you evaluate PPO networks more accurately:

• Provider Counts – These include each dentist who is under contract with the carrier. Each provider is counted only once. A network using this count may be appear to be significantly smaller compared to other carriers’ networks that are using different counting methods.
• Locations – This reflects the number of office locations where dentists are under contract with a carrier, but does not represent the actual number of practicing dentists at each site.
• Access Points – They identify the number of dental providers at each office location where they practice. Using this method of counting, a dentist who practices at three different locations would be counted three times in the network, which could lead to scheduling problems.

Disruption Analysis

Like network size, carriers also have different ways to define disruption in PPO networks. The goal of this comparative analysis is to determine what disruption may occur with a new dental plan and network change. A positive comparison will create less disruption and fewer employee complaints about the new dental plan. It is important for the PPO network to include the employees’ preferred providers.
You can easily gather this information by asking employees to identify their key dental providers and by reviewing a recent history of paid claims. If the employer’s health plan has a network, separate the dentists who are not affiliated with the PPO. Likewise, if the existing dental plan does not offer a PPO, develop a list of utilized dentists. Compare the lists you have compiled against the dentists on the network under consideration. Employee satisfaction will be high if there is a good match of dentists and if currently utilized non-PPO dentists are on the new network.
During a plan year, employers frequently hire employees who are not familiar with dentists in that market. Also, current employees may decide to switch providers. Make sure the dentists on the new PPO network are near the employees’ workplace and homes, not on the other side of the city

Contracted Fees and Services

Dentists participating in PPOs agree to provide care based on a negotiated fee structure, offering employees guaranteed costs for contracted services. However, these fees probably vary with each dental carrier and the details of their agreement may be different for each dentist. Some networks provide a flat percentage discount on dentists’ usual fees. Others contract for fixed fees with a wide range of percentages off the usual and customary fees.
When evaluating PPOs, determine whether contracted dentists offer guaranteed discounted fees for all covered procedures or a portion of covered procedures. Request each carrier under consideration to provide information in writing describing the fee structure and what is covered. Ask if dentists are required to give guaranteed fees for every procedure covered under the contract.
It is also important to clarify the fee structure for employees using out-of-network dentists. Each carrier covers these services differently, so you need to include this information in your employee benefits education sessions. Otherwise, employees may be hit with unexpected dental costs, which may lead to a dramatic increase in dissatisfaction with the dental benefits.

Credentialing

Carriers should enforce credentialing requirements for dentists to remain on their network. That would include verification of malpractice insurance, and no suits filed, and state insurance department confirmation that dentists are licensed. A carrier’s law department and dental consultants should review any disciplinary action or malpractice suits made against a dentist. These re-credentialing processes should be repeated periodically to ensure that dentists are meeting the carrier’s standards.

Carrier Reputation

The quality of the employees’ experience with a PPO network also depends on the carrier’s customer service and claims processing. Many insurance companies talk about providing great customer service, but few actually deliver.
Most employees visit their dentists more than once a year, so the frequency of claims is higher than that of medical plans, yet the cost per claim is lower. However, with a higher frequency of claims, there is a greater potential for error. Look for carriers that provide the customer service your customers expect with demonstrated sustainable service levels over time. Verify that carriers can manage employee information accurately and efficiently. Review their client reporting capabilities and evaluate their financial expertise and actuarial and underwriting experience.
Evaluating PPO Networks

Look for networks that provide access to dentists preferred by the employee group and clearly defined contracted rates. Also, look for carriers that are a good financial match for your groups. In addition, work with a carrier that has a reputation for supporting its PPO plan with the excellent customer service and administrative structure that employers and employees expect.
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Karen M. Gustin, LLIF is vice president-group marketing and managed care for Ameritas Group, a division of Ameritas Life Insurance Corp. with headquarters in Lincoln, Neb. Gustin’s tenure with Ameritas Group spans 24 years. She is involved with the National Association of Dental Plans (NADP), serving on the board and chairing the Statistical Task Force. For assistance in understanding insurance plans and carrier choices or comparing coverage options, contact the Ameritas Group marketing department at 800-776-9446.