SUMMARY
Evaluating your carrier’s dental network is important to ensure your membership can easily access care. Traditional logic may state that the “size” of a dental network is the best evaluation criteria. But “size” isn’t always the definitive measure. In fact, even the definition of “size” is a moving target. Is the carrier counting offices? Or dentists? Where are providers located in reference to your population? How are the dentists compensated?
This article outlines five criteria that can help employers, plan sponsors, and benefit consultants evaluate different carriers’ networks. Understanding the nuances of what defines a carrier’s network and how it is constructed from a contractual basis can be valuable in making an assessment.
Each criterion may not carry the same weight for a specific group. However, knowing what’s under the hood can be advantageous.
ACCESS POINTS VERSUS DENTISTS
Access points are one of the most common statistics cited as a measurement of a network’s strength. But do those counts clearly represent the members’ ability to access care? Access points are typically a count of offices or “doorknobs” (industry jargon) in a network. However, they may not properly quantify how easily your members can access treatment.
Many dentists practice in multiple locations, which means access points could count a single dentist multiple times. There are also single offices with a large staff of dentists that would only be counted once. A good dental network should have a large number of dentists with a mix of private practice dentists as well as large dental practices or dental service organizations (DSOs).
GEOGRAPHIC STANDARDS
Next, it’s important to evaluate where the dentists’ physical offices are located in reference to where your members live and/or work. Each covered member and their family, if applicable, needs to have a provider in a reasonable distance to offer convenient access to care.
Large urban areas often offer better access than rural areas. That’s why a geographic access study should be conducted to determine the proximity of the network’s dentists in relation to the group’s membership. There are areas of the country known as “dental deserts” where there are very few practicing providers. Knowing how conveniently your population can access care is an important criterion in evaluating a network.
BeneCare Dental Plans’ standard is to have at least one primary care dentist within 10 miles of 90% the plan members’ homes and one of each specialist within 20 miles.
NETWORK CAPACITY
Another consideration of a network’s strength is its capacity to accept new patients. A network can have a sufficient number of practicing dentists and specialists in an acceptable distance of your population, but do they have the bandwidth to accept new patients? A network doesn’t adequately serve your group’s population if the membership can’t get an appointment in a reasonable time period or if the dentist isn’t accepting new patients.
BeneCare Dental Plans measures its dentist-to-member ratio to help ensure the ability of its networks to serve both existing and new patients. BeneCare’s participating providers are required to offer a routine appointment within 10 business days of a request and within 24 hours of an emergency request.
DIRECT CONTRACTING VERSUS LEASING & STACKING
Does the carrier hold direct contracts with providers in its network? Or is the carrier cobbling together its network by leasing and stacking dentists from other carriers or networks?
A “direct contract” network signifies the carrier has negotiated an agreement directly with each provider in its network. This is important because a directly contracted provider has agreed to the terms of participating in the carrier’s network and agrees to accept the fee structure.
Network leasing and stacking refers to the practice where networks of dentists are leased to or layered on top of the policy-issuing carrier’s, often without direct contracts with the dentists. Essentially, the carrier is “re-selling” someone else’s network. However, the providers may not know it and haven’t agreed to the reselling carriers’ terms and conditions or fee schedules.
Leasing and stacking create a tangled web of complex relationships between dentists, carriers, and third-party administrators. The lack of transparency can be detrimental to the dentists and their patients. Many state regulators are requiring carriers to informed dentists of the practice and giving them the option to opt out completely.
BeneCare Dental Plans directly contracts with each dentist and specialist who participates in its networks. This means every provider in BeneCare’s networks has agreed to the terms and conditions of participating with BeneCare and to its reimbursement schedule for services. BeneCare NEVER LEASES its network to any other carrier.
REIMBURSEMENT MODEL
The carrier’s provider reimbursement model can directly affect the cost and delivery of care to your group’s membership. There are a number of reimbursement or payment methodologies employed in the industry. Each has distinct advantages and disadvantages. Some examples include: fee-for-service, capitation, and reference-based pricing.
BeneCare Dental Plans has used an outcomes-based reimbursement model with a shared-risk arrangement since the company was founded in 1979. The principle behind the methodology is quite simple — give the dentists a financial incentive to improve the patient’s oral health and reward them accordingly. The end result is better oral health for the member and lower cost for the employer or plan sponsor.
To help you understand the pros and cons of different reimbursement strategies, BeneCare has dedicated an entire blog post to the topic. Please refer to “Reimbursement Strategies — How They Can Affect the Cost and Delivery of Care.”
OTHER RESOURCES
For additional information about the cost-containment aspects of BeneCare’s outcomes-based reimbursement model, refer to the “Three Keys to Bending the Cost Curve” and the New Castle County Chamber of Commerce case study, “How Utilization Can Stabilize Cost.”