Managed Care & PPO

General Explanation and Definition of Terminology

Technically managed care and PPO plans are very distinct entities but often the terms are incorrectly used as if interchangeable. The only real common thread between the two forms of benefits are that both utilize a limited network of doctors who have chosen to contract directly with the insurance company, usually offering the insurance company a discount in exchange for the prospect of being associated with the network for the business that it brings into the office.

PPO

The preferred provider organization (so named because the provider is preferred by the insurance company due to the discounts provided) comes in several different flavors.

Most often PPO coverage will allow patients to choose any doctor but offers the insured strong incentives in the form of lower co-payments to seek care with one of the participating doctors.
Some PPO coverage will not allow the insured the option to seek care outside of the network of contracted doctors. Exceptions are sometimes made in the case of covered services for which no convenient provider can be found to provide the particular service.

The distinguishing characteristic of the PPO as opposed to the managed care plan is that doctors are not pre-paid for care and paperwork must be submitted to the insurer before actual payments, based upon the services performed for you, are made to the doctor. Sometimes, you will hear the doctor or a staff member refer to the PPO write-off. That is the amount discounted from the regular fee and this is the only time that a doctor may legally discount a fee after insurance has paid.

Managed Care

Managed care plans also come in various forms. Most commonly managed care plans pay each doctor or dental office a flat per patient fee each month, called a capitation fee, for each patient assigned to that doctors office. This "retainer" entitles the subscriber patient and family members to certain fully covered services, usually the least expensive services, as well as a significant discount for other services. Often there are surcharges or office visit fees of between 10 and 25 dollars for each visit and there are usually other "hidden" fees such as those for appointments missed by the patient but not cancelled within 24 hours of the appointment time.

The distinguishing characteristic of the managed care plan as opposed to the PPO is that doctors are pre-paid for care and co-pays when applicable are pre-determined by contract between the doctor and the insurer. Because patient's are almost always required to utilize doctors in the Network and because many services have been pre-paid by the insurer, (usually at a very low rate) there is a strong disincentive for doctors to go out of their way to provide the highest level of service or quality of care.

Furthermore, some managed care company's severely limit access to expensive procedures or certain types of specialty care.

Dental care consumers choosing managed care should be aware of, and be willing to live with the limitations imposed by these types of dental care plans. There is a reason why the premiums for this type of plan are the lowest of all types of health care insurance. In many ways such plans can be compared to discount airline fares with restrictions; while you will surely reach your destination, there are restrictions as to when you may travel and financial penalties for failing to follow the rules in the fine print. The following guidelines will help in choosing whether such a plan is right for you.

Managed care dental plans seem to work out best for:

Those on fixed incomes and those whose time is flexible and are available for appointments in off hours, such as retiree's.
Those who live and/or work close to urban areas.
Those who generally enjoy good dental health and are primarily in need of dental well care on a semi-annual basis.

Managed care dental plans seem to work out worst for:

Busy professionals who are often called in to work on off days or who are likely to have schedule changes at the last minute.
Those who live and/or work on the fringe of the suburbs or in the country.
Those who generally need large amounts of dental work on an ongoing basis.

At Glick Dental Associates we are in a position because of our size and standing with insurers to provide the highest level of service and quality of care regardless of which type of coverage you choose. However, we recommend that you choose the type of insurance based upon your individual needs and understand fully the pros and cons of the plan you choose.