What Good Senior Dentals Can Be Sold by Phone?

[cedwards]

Which does not answer my question.

A carrier which shall remain nameless would tell us they reimbursed in the 90th percentile based on ADA pricing codes.

Problem with that is, there is no such thing as ADA pricing codes.

I have tried for some time to find out what carriers use to determine R&C and either no one knows or they just aren't talking.

From the link below, it looks like the ADA is forbidden by law from setting the pricing of dental services but they do a nationwide survey of dental service fees. There's a disclaimer on the link that says "The published survey data should not be interpreted as constituting a fee schedule in any way, and should not be used for that purpose. The ADA is forbidden by federal law to set or recommend fees. Dentists establish their own fees based on their individual practice and market considerations." My question would be why do the survey then?

I'll check with CUL and see what they get their data from.

Fees for Dental Procedures

 

[somarco]

As the referenced link says, it is little more than a survey and the info is only available to ADA members.

My guess is the disclaimer you reference is to avoid the appearance of price fixing.

 

[yorkriver1]

How do they define reasonable and customary?

Do they use 100% of R&C, or 80%, or 60%?

Group America used to play games like that on their dental plans. If you had a 50% benefit based on 80% of R&C they actually paid 40% (50% of 80%). Really made life difficult for the agent that sold their plan

Somarco, I have a recollection of being sent to the corner by a plan admin when I was first soliciting proposals for small group insurance. I couldn't answer, had no idea that was even a question. Learning curve. Definitely a significant metric for plan comps before network plans became the dominant plan design. Network plans: mostly no more of "that call" from a client being balance billed. Down to the question: what % of UCR they reimburse, let alone how they get their schedule of UCR in the first place, it might not always be easy to find someone at the carrier who can answer that. So, I went looking.

Here is what I found about this topic. 1. an organization, Fair Health, that functions sort of like ISO does for P&C, a contracted claims/rates data source for rate setting.

FH Consumer Cost Lookup

2. UHC's discussion of how they set UCR, which also relates to the reason Fair Health was created:
Legal - Payment of Out of Network Benefits | UnitedHealthcare

 

[Chazm]

I send some of mine to Delta, and would be an agent, but they don't sell individual dental through agents. You could shop a web health site, see what is offered in your zip code area. Some have explored the discount plans or HMO's. These I rarely sell, but if a client insists, I may show them sites to enroll. Too many narrow networks/complicated fee schedules. A few clients, coming off corporate benefits or small business owners like to buy dental, no matter the cost. If it makes them happy, OK.

Maybe it's just by area. Here in Florida I offer delta.

 

[yorkriver1]

Maybe it's just by area. Here in Florida I offer delta.

There are a couple plans I will soon be able to access that use the Delta network, but aren't branded as Delta.

Maybe some day here. Thanks.