Clark stinks when it comes to dental HMOs!

Insurance
1

In this 2017 video, Clark Howard speaks favorably about the dental HMO as a concept. However, a portion of this article reads:

Satisfaction with an HMO is, sadly, very uncommon. People who speak positively of their HMO experience typically didn’t use their insurance plan.

The way a dental HMO plans like Deltacare USA work is through a “capitation” system.

To receive care, you have to choose an in-network dentist. This means the dentist has agreed to sign a contract with your insurance company in exchange for being assigned a list of patients who can only use them for dental care.

Each month, that network dentist will be sent a check for a few bucks for each name on that list, regardless if they walk through the door or not.

In the case that you do make an appointment for preventive services (hopefully at least twice per year), your out of pocket cost will be pretty low. However, the dentist is also very poorly compensated for this type of appointment, only making a few dollars for a cleaning, exam, and x-rays.

This type of reimbursement would not even cover the cost of materials used. Dentists may then resort to charting more extensive treatment for issues that may be addressed in a more conservative manner. (If you think this sounds sketchy, you would be correct.)

For example, say you plan to only take advantage of routine cleanings to prevent decay and plaque build up. During this visit, your dentist or hygienist may find areas of concern that the typical dentist may think needs a filling.

Since s/he needs to make money to keep the doors open, you may find yourself with a root canal on your treatment plan instead of a filling. And since you need a root canal, a crown is also necessary to regain your tooth structure.

While this would be bad enough without the dishonesty factor, an HMO plan would pay VERY little of your procedure.

This may leave you with hundreds of dollars of expenses out of your own pocket.

2

No honest, reputable dentist signs up for DMOs. When dentists try to sell their practice, you will often see the words “No DMOs” in the practice description. NOBODY wants to buy a practice tied to DMOs

There is simply no way to make any money at all treating DMO patients. So dentists stoop to various tricks to turn a profit:

  1. Rationing appointments for DMO patients- spacing them very far apart. Ask for an appointment as a DMO patient, then call back using a different name and claim you are a cash patient. See the difference in when you can get in.

  2. Charging for things not ordinarily charged for- infection control and lab fees are the two big ones.

  3. Doing unnecessary treatment. One filling might be a money-loser, but if you do three more unnecessary ones in the same visit the dentist may turn a profit.

  4. Refer any treatment out that you would normally do- extractions, root canals, gum surgery. Specialists get a different deal. The less treatment a general dentist does on a patient, the more money he makes, as the monthly capitation payment is the same.

  5. Upcoding “free” procedures to ones with copays. A simple cleaning magically becomes a “scaling and root planing.” Often clinical findings are falsified to justify the upcode.

Over the years, I have reviewed tons of treatment plans for patients on DMOs. Almost none were appropriate.

DMOs (dental HMO’s) were a cruel joke invented by the insurance industry. From their point of view, it drastically reduces claim administration costs.