Fearless Dental
Taking the Mind-Numbing Pain Out of Finding the Right Carrier

Welcome to Part II of California Broker’s 2008 Dental Survey. We’ve asked the top dental providers in California to answer 28 crucial questions to better help you, the agent, understand their benefits, features, and services. Look for Part III in the September issue. Read the responses and sell accordingly.

12. What percentage of your network is closed to new enrollment? How many offices does this represent?

Aetna: For California, it is around 4%. Participating PPO dentists contractually cannot close their offices to new patients.

Ameritas PPO: 114 Offices (<1% of the panel) are closed to new enrollment.

Ameritas/FDH Network: None.

Anthem Blue Cross: All of our dental PPO providers are accepting new patients.

BEST Life: All participating PPO dentists are accepting new patients.

CIGNA Dental: In California, the total number of general dentist network locations is 1,513. Of those, 1,345 are open to new membership. DPPO network offices do not close to new membership.

Delta Dental: Our fee-for-service dentists do not close to new enrollment. The number of DHMO dental offices closed to new enrollment varies, but is generally less than 10%.

Dental Health Services: About 5% of network dentists are closed to new enrollment.
Golden West: About 5% of our DHMO panel offices are closed to new members. This represents about 210 provider locations.

GroupLink: N/A, see response to Question 11.

Guardian: In California, 10 of our 27,000+ locations of participating dentist offices are closed to new PPO patients, which represents 0.04% of our network. Nationally, 409 locations are closed to new PPO patients, representing 0.04% of our network. For the DHMO, 2% of our participating dentist offices are closed to new enrollment.

Health Net Dental: For DHMO, fewer than 8% of general dentist offices are closed to new enrollment. The PPO network is accepting all new Health Net Dental members.

HumanaDental: Under HumanaDental’s provider contract, participating dentists must schedule and treat members without discrimination, including benefit or payer differentials. Because this is a fee-for-service reimbursement program, closed practices are not common.

MetLife: Nationally, about 1% of our participating PPO dentists have requested that their names be removed from our PPO provider listing for purposes of not accepting new MetLife-eligible patients. For DHMO, fewer than 8% of general dentist offices are closed to new enrollment.

Principal Financial Group: Less than 1% of the offices participating in our network are closed to new enrollment.

United Concordia: 62 DHMO offices are closed to new enrollment. 95.4% of facilities are open to new patients.

Western Dental: Less than 3% of our network providers are closed to new enrollments - about 60 offices.

13. Do all of your contracted offices accept every benefit level sold by your company or do they have the option to pick and choose only the programs with co-payments they want to accept?

Aetna: All DMO offices accept all of our coinsurance and fixed copay-ment plan designs. In addition, all our PPO offices accept the negotiated charge from Aetna and the patient.
Ameritas PPO: All offices accept all coverages, except if sold in conjunction with the FDH PPO. The FDH PPO plans only can utilize the FDH panel.

Anthem Blue Cross: Anthem Blue Cross encourages all Dental Blue providers to accept all plans offered. The same is true for our traditional Prudent Buyer PPO and DHMO dental plans.

BEST Life: All contracted offices accept every benefit level sold by BEST Life. Furthermore, by contract, all providers will honor the PPO discounts on all procedures, including non-covered services. They must also honor a discount for members who are within a waiting period or who have exceeded their annual maximum.

CIGNA Dental: All contracted PPO offices accept all of the plan designs that we offer. All contracted CA DHMO offices also accept all of the plan designs that we offer.

Dental Health Services: All new dentists are contracted for all plans offered by Dental Health Services.
Golden West: Most of our DHMO panel offices accept all of our plans. However, they can choose specific plans in which to participate.

GroupLink: Our leased networks would track this.

Guardian: All contracted PPO offices accept all of the plan designs that we offer.

Health Net Dental: For PPO, all participating PPO dentists accept all of our plan designs. They cannot pick and choose which Health Net Dental plans to accept. For DHMO, when contracting with a dental care provider, it is understood that the dentist will accept all DHMO plans. A few contracted dentists do not participate in some of the older custom plans.

HumanaDental: The PPO contract is for all network-based programs, excluding DHMO, which requires a separate agreement.

MetLife: For the PPO, all participating PPO dentists accept all of our plan designs. They cannot pick and choose which MetLife plans to accept. For the DHMO, when contracting with a dental-care provider, it is understood that the dentist will accept all DHMO plans. A few contracted dentists do not participate in some of the older custom plans.

Principal Financial Group: Providers can choose to participate in our PPO and EPO networks. Within each option, providers need to accept all benefit levels sold by our company.

United Concordia: If an office is open to new enrollment, they accept
all plans.

Western Dental: The entire network accepts all of the new Series 7
plans.

14. Do you have a way to monitor the length of time patients have to wait in the doctor’s office?

Aetna: A Semi-annual written survey is collected from all CA DMO GP’s and specialists.
Ameritas PPO: Yes, an office evaluation worksheet is sent to each dentist along with the initial application. The office-wait time is questioned at that point. In addition, surveys are performed to address insureds’ satisfaction with office wait times.

Anthem Blue Cross: Yes, we monitor this as a metric in our member satisfaction surveys. Through our complaint/grievance tracking processes, such issues as wait times are logged and monitored. Additionally, we monitor appointment wait times and emergency wait times through surveys conducted by our organization.

BEST Life: FDH monitors accessibility and wait times through their Customer Service and Provider Relations departments.

Blue Shield: Yes, we monitor and track wait times several ways. We document member complaints on this issue in our customer service workbench and track them electronically until they are resolved. We also conduct an annual member satisfaction survey, which contains specific questions about wait times with our network offices.

CIGNA Dental: The network management team monitors wait times in our DHMO general dentist facilities via monthly telephone calls. Additionally, we are able to identify lengthy wait times through our patient-satisfaction surveys.

Delta Dental: Delta Dental conducts random enrollee surveys each quarter, which include questions about the enrollee’s waiting time to schedule dentist appointments and other customer satisfaction issues. The appointment availability at DHMO offices is also monitored via regular office visits from a Delta Dental representative.

Dental Health Services: Yes, we monitor our members’ experiences through frequent member surveys and regular on-site dental office visits.

Golden West: Yes, access is measured through member-satisfaction surveys in addition to on-site reviews and word-of-mouth from our members.

GroupLink: Our leased networks would track it.

Guardian: We do not monitor appointment scheduling or wait times for the PPO plan, although every month we send member satisfaction surveys, which include questions concerning wait times, to randomly chosen PPO members who have been to a network dentist within the previous 90 days. The DHMO has established access standards and monitors access by Network Management Representative office maintenance visits, quarterly mailing access monitoring forms, member satisfaction surveys, transfers, and grievance data. Telephone calls are utilized on an “as needed” basis.

Health Net Dental: For the PPO, we monitor patient impressions of wait time through monthly satisfaction surveys. For the DHMO, Health Net Dental monitors the length of time that patients wait in the reception area and the operatory through the quarterly accessibility survey and service visit reports by provider-relations representatives. In addition, we track wait times through a monthly report and member satisfaction survey.

HumanaDental: We rely on member calls to keep us apprised of scheduling issues. Sometimes, the member is limiting his/her options (i.e., after 5 p.m.), which is discovered through discussion with our customer-relations representatives. If the issue becomes chronic, the information is forwarded to our National Dental Network department because additional providers may be needed in the area.

MetLife: For the PPO, we monitor patient impressions of wait time through monthly satisfaction surveys that ask this question. For the DHMO, SafeGuard, a MetLife Company, monitors the length of time that patients wait in the reception area and the operatory through the quarterly accessibility survey and service visit reports by provider-relations representatives. In addition, we track wait times through a monthly report and member satisfaction survey.

Principal Financial Group: We do not monitor this.

United Concordia: Yes, it is monitored through member surveys, a customer service grievance process and periodic phone audits of the offices.

Western Dental: Western Dental monitors patient’s length of time by on site reviews, surveys, and questionnaires. In addition, our staff model offices utilize Quality Assurance Management System
a state-of-the-art, proprietary software tool that tracks measurable items, such as wait times. This ensures that our members have timely access to quality dental care.

15. Are there plenty of providers who stay open late and are open on Saturdays?
Aetna: Office hours are set by each dental office. We document dentists’ office hours as part of the credentialing process. We use the information to balance networks by contracting with dentists who offer weekend and evening hours.

Ameritas PPO: Yes.

Ameritas/FDH Network: Yes.

Anthem Blue Cross: Anthem Blue Cross offers the option of dental offices with varying hours of operation, but this is the choice of the individual dental practice.

Best Life: Yes, with more than 15,300 providers in the state, many have extended and flexible hours.
Blue Shield: This varies by provider, but some do stay open late and are open on Saturdays.

Delta Dental: Our online dentist directory contains information on hours and access, including maps and languages spoken, or enrollees can call a toll-free number to request a list of dentists in their area with extended and Saturday hours. In addition to posting hours and access, DHMO network dentists are required to provide 24-hour emergency services to DeltaCare USA enrollees at all times.
Dental Health Services: Many of our participating dental offices offer extended hours, including weekend hours.

Golden West: Yes, many of our providers offer evening and Saturday appointments. Our Member Services Department can help members with details.

GroupLink: Our leased networks would need to advise on such schedules.

Guardian: Yes, many PPO and DHMO provider locations have extended or weekend hours.
Health Net Dental: Yes, most providers offer extended service hours.
HumanaDental: Office hours are not tracked.

MetLife: For the PPO, all participating MetLife PPO dentists must provide acceptable hours of service and have established emergency care and off-hour protocols. For the DHMO, SafeGuard, a MetLife Company, contracts with individual dental practitioners, many who have evening and Saturday hours.

Principal Financial Group: Members can see any provider of their choice, which can include those who have extended hours.

United Concordia: There are providers in every market who have extended hours.

Western Dental: Yes, many of our IPA providers have evening and Saturday hours. The Western Dental Staff Model Offices are open from 9:00 AM to 8:00 PM, Monday through Friday and 8:00 AM to 4:00 PM on Saturdays.

16. With respect to your mid-range benefit level, what is the specific amount of capitation paid to the general dentist? Do you offer validation for these amounts?

Aetna: We establish varying compensation rates under each customer’s plan for subscribers, spouses and children. Monthly compensation rates are based on case-specific dental experience, community averages, employee statistical data, and plan design. For DMO/managed dental plan, participating providers get a monthly check based on per member, per month compensation basis, subject to a guaranteed chair-hour rate. Actual capitation amounts are proprietary.

Ameritas PPO and the FDH Networks: No capitation is paid to PPO providers.
Anthem Blue Cross: Proprietary.

BEST Life: We do not compensate our providers through capitation. Our indemnity and PPO plans allow patients to utilize providers of their choice.

Blue Shield: This information is considered
proprietary.

CIGNA Dental: This is proprietary information.

Dental Health Services: Dentist capitation data is considered proprietary.

GroupLink: We are not a DHMO, so this is not applicable.

Guardian: Not applicable to the PPO dental products Guardian offers in California. Capitation amounts paid to the general dentist vary based on plan design, adult or child, and region.

Health Net Dental: For DHMO, capitation is actuarially set by plan design and that information is proprietary. Capitation is augmented by supplemental payments for certain procedures. In addition, the plan pays fees for each member visit.

HumanaDental: Managed dental care capitation varies by plan schedule and geographic location.

MetLife: For DHMO, capitation is actuarially set by plan design and that information is proprietary.
Capitation is augmented by supplemental payments for certain procedures. In addition, the plan pays fees for each member visit.

Principal Financial Group: N/A

United Concordia: Specific capitation amounts are considered proprietary information. Our DHMO dentists get supplemental reimbursements in addition to monthly capitation payments.

Western Dental: Series 7 plans reimburse providers with capitation and supplemental payments. Total compensation, as with fee for service designs, depends on how much treatment is provided.

17. Are there incentives for the provider to be thorough?

Aetna: Quality management programs are designed to help protect
members and providers.

Ameritas PPO: Yes, a utilization review is performed quarterly. If standards are not met, it could result in the provider’s termination from the plan.

Ameritas/FDH Network: N/A

Anthem Blue Cross: Dentists cannot increase their revenue through incentive programs. When deemed necessary and appropriate, supplemental payments may be made to participating dentists. However, these payments are not part of any bonus or incentive program.

BEST Life: FDH administers comprehensive utilizations reviews for dental necessity and appropriateness of care.

Blue Shield: Appropriate care provided by dentists in our networks is measured continuously through numerous oversight mechanisms. While routine treatment plans are carried out by dentists without prospective review, more complicated treatments are evaluated by our dental consultants. All dentists involved in our review process are fully licensed. Our clinicians are also actively involved in the annual review of dentist records. A random sample of each dentist’s records is selected for scrutiny by our dental consultants. Necessary recommendations are made to any dentists who do not meet our quality standards and follow-up audits are conducted to verify corrective action has been taken.

CIGNA Dental: Our Integrated Quality Management Program drives overall quality and better outcomes across our entire network. While we do not provide incentives, the expectation is that the providers in our networks meet professionally recognized standards of care.

Delta Dental: There are no financial incentives because Delta Dental’s contract requires a dentist to be thorough and to deliver quality healthcare. Delta Dental monitors dentists’ performance through enrollee complaints, on-site quality assessment surveys, and dental office reviews conducted by licensed dentists and monitors based on our utilization management system.

Dental Health Services: Our supplemental payments and rigorous quality assurance program are designed as incentives to provide appropriate and thorough care.

GroupLink: This is usually asked in context of a DHMO arrangement. Providers under our programs are paid based on a fee-for-service basis or a negotiated fee schedule.

Guardian: Our PPO fee schedules and plan provisions are adequate to encourage proper care. We do not offer incentives. Guardian requires participating dentists to treat PPO members the same as any other patients and we investigate all quality of care complaints from members. Our DHMO plan schedule, capitation, office visit fees, supplementals, and chair hour guarantees are adequate to encourage appropriate care. MDG requires participating dentist to treat MDG members the same as any other patient, and we have a grievance process in place to follow up on all quality of care complaints from members.

Health Net Dental: There are no monetary incentives to dentists, but they are expected to perform in accordance with the high standards of competence, care, and concern for the welfare and needs of participants.

HumanaDental: Fee-for-service reimbursement encourages thorough treatment. Member complaints are reviewed by our Quality Assurance Department and through our standard grievance process.

MetLife: There are no monetary incentives to dentists, but they are expected to perform in accordance with the high standards of competence, care, and concern for the welfare and needs of participants.

Principal Financial Group: Being thorough is an expectation and we do not provide incentives to meet expectations. All providers in our networks or those we might recommend must meet strict credentialing requirements. This means they have all been independently reviewed and found to have proper professional credentials and a verified history of responsible billings. However, a member is free to choose any provider.

United Concordia: Participating DHMO primary dentists get supplemental reimbursement on most highly utilized procedures in addition to monthly capitation and member copayments.

Western Dental: Western Dental Services Inc. may pay the dentist a bonus based on exceeding standards specified by Western Dental with regard to accessibility of services and quality of care.

18. Do you provide coverage for all types of specialist referrals?

Aetna: Yes.

Ameritas PPO and the FDH Networks: Yes, all specialists are considered for claim reimbursement.

Anthem Blue Cross: Yes, specialist coverage is a benefit for the Dental Blue PPO plans, but referrals are not required. Dental Blue contracted dentists are credentialed providers. And our contracted specialists, such as oral surgeons, periodontists and endodontists participate in all three Dental Blue networks. The same is true for our traditional Prudent Buyer dental PPOs.

BEST Life: Yes, specialists are covered at full contract benefits as described in our indemnity and PPO plan certificates. Our orthodontic plan is available for all of our PPO and indemnity plans.

Blue Shield: Yes, Prudent Buyer dental PPO
plans.

CIGNA Dental: Coverage is provided for periodontic, endodontic, oral surgery, pediatric dentistry, and orthodontic specialty referrals for DHMO plans. Our DPPO/DEPO and Dental indemnity plans do not require specialty referrals.

Delta Dental: Fee-for-service enrollees can visit any licensed dentist; referrals are not required for specialty care. If the treatment plan is complicated or expensive, Delta Dental recommends that the enrollee ask the dentist to submit a predetermination request to Delta Dental, which will eliminate guesswork about allowable costs and the enrollee’s out-of-pocket expenses. For DHMO patients, referrals to specialists are not charged against the dentists’ capitation payments. As a result, general dentists are not discouraged from making specialty referrals when necessary. However, while prosthodontic procedures performed by the general dentist are covered, services from a prosthodontic specialist are not covered under the DHMO plan. Group coverage levels and the group’s contractual agreement determine coverage for other specialist procedures.

Dental Health Services: Our plans provide specialty coverage for endodontics, periodontics, oral surgery, pedodontics, and orthodontics.

Golden West: Yes, our DHMO and PPO plans include coverage for most specialists.

GroupLink: N/A.

Guardian: Specialty care referrals are not required under Guardian’s PPO plans; members may seek treatment from any specialist without obtaining advance approval. We provide coverage for all types of specialist dentists in the PPO network, including orthodontists if a member’s plan has orthodontia benefits. The DHMO provides referrals to Endodontists, Orthodontists, Oral Surgeons, Pediatric Dentists and Periodontists.

Health Net Dental: For PPO, all claims for services by licensed dental practitioners will be considered for reimbursement based on the participant’s plan design. For DHMO, plans cover endodontics, periodontics, oral surgery, pedodontics, and orthodontics.

HumanaDental: Members can be referred to in-network and out-of network specialists, depending on the accessibility of the appropriate specialist in his or her area.

MetLife: For PPO, all claims for services by licensed dental practitioners will be considered for reimbursement based on the participant’s plan design. For DHMO, plans cover endodontics, periodontics, oral surgery, pedodontics, and orthodontics.

Principal Financial Group: Generally yes.

United Concordia: Yes.

Western Dental: Specialty coverage is available in all of our group plans. Oral surgery, periodontics, endodontics, pedodontics, and orthodontics are covered specialties.

Dental Survey Part I