Some health funds use the term ‘preferred provider’ – what does this really mean? You might be forgiven for presuming that these ‘preferred providers’ are preferred because they provide a higher standard of clinical care, or a better patient experience. However, this is not necessarily the case. So, with thanks to the Australian Dental Association read on to find out more about preferred provider schemes.
The ‘preferred providers’ are not actually preferred because of dental ability but because they meet the fee criteria set by the health funds and have agreed to be contractually bound to the health fund. Some health funds are attempting to force their members to see the health funds’ dentist of choice, rather than their regular dentist. Here’s some questions and answers to help you to understand more about this topic.
Q1. Why is it important I can choose the dentist who will provide my care?
You need to be comfortable in talking and being treated by your dentist of your choice. You need to be comfortable in the fact that your dentist is recommending the best treatment for you. Continuity of care is very important in dental care delivery. Your dental health care will be more effective if you maintain your relationship with your dentist, rather than having your choice of dentist dictated to by your health fund.
Q2. What exactly is a contracted dentist?
Contracted dentists have agreed to provide dental treatment at an agreed fee with the health fund. The health funds advertise “no out of pocket expenses’ or “reduced out of pocket expenses” – BUT only if you see one of their dentists.
Q3. Why don’t health funds just increase the dental rebate?
This is a very good question and you should ask your health fund this question. One health fund has not increased dental rebates across the board since 1994. Many funds do not increase dental rebates annually. Private health funds in Australia have made in excess of $7.2 billion surplus (profit) in general treatment cover in the last 10 years, which has not been returned to contributors as increased rebates. It is now $3billion surplus in just the last 3 years.
Q4. How are health funds influencing my right to choose my dentist of choice?
Health funds have openly and aggressively campaigned to get dentists to “sign up” to their contracted provider arrangements. Health funds are openly promoting to patients that they should see a health fund contracted dentist. Some health funds are offering a higher dental rebate for each item of service if a contracted dentist performs the procedure. Some funds have even bought their own dental surgeries and employ their own dentists.
Q5. Is this fair?
The ADA thinks this very unfair. After all if contributors pay the same health fund premiums then all contributors should get the same rebates. If you get a lesser rebate you should pay a lesser premium.
Q6. What if I need to see a specialist dentist? Are there any contracted specialists?
Very few, and some of these are not members of the ADA. This means they fall outside our area of who make the commercial decisions for them and they are then contracted to a health fund in this way.
Q7. Why isn’t my dentist a “preferred practitioner”?
The “preferred practitioners” are not actually preferred because of dental ability but because they meet the fee criteria set by the health funds and have agreed to be contractually bound to the health fund.
Q8. My health fund says my dentist is too expensive and my gap will be too high and says I should see a contracted dentist. What should I do?
ADA National fee surveys show that dentists’ fees over the 17-year period from 1996-2012 have increased on average by less than 5% annually.
- You should ask what your health fund average premium increases have been over the same period. The Federal Government has been subsidizing health fund premiums by 30%. Whilst this has recently been reviewed there is still substantial subsidy on offer.
- You should ask how much your health fund’s dental rebates have gone up over the same period.
- The lack of increased dental rebates explains the increasing gap between fee and rebate. This has not been caused by your dentist.
Q9. If the health funds do not permit the dentists who are contracted to them to increase their fees in line with practice cost increases, is there a risk that the quality of dental care may suffer?
The ADA believes this may cause “tiered’ levels of care. Preferred contracted provider schemes have not been successful anywhere else in the world. If you pay the full premium you deserve the best care and the same rebate as any other contributor regardless of which dentist you choose to see.
Q10. What can I do about this contracted dentists’ issue?
You should send a letter of complaint to the manager of your health fund if you are not happy. You have a right to expect the dentist of your choice will provide the service you need and you will receive the same rebate as other policyholders without discrimination. There are funds that do not have preferred provider contracts. Talk to your dentist about transferring your membership at no penalty to you. Further obligation free advice on health funds is available at on the ADA web site www.ada.org.au
