In a dental maintenance organization (DMO) insurance plan, a primary care dentist (PCD) is the primary dental care provider for an insured patient. This dentist is in charge of coordinating and integrating the patient’s dental care. The PCD acts as a stepping stone to dental specialists. Before visiting a specialist, patients with this type of dental plan must get a referral from their primary care dentist. This strategy could help patients and insurance companies save money on dental care while also giving them access to a wider range of services and higher-quality care.
Until recently, dental insurance options were limited. Basic dental maintenance, such as cleanings and cavity fillings, was the most common type of insurance offered. Major dental work was frequently uninsured. More complex procedures, such as getting braces, were only covered dental policies that were linked to medical insurance. In both cases, however, the insured had direct access to any dentist, general or specialist, simply calling and scheduling an appointment with a dentist who accepted the type of insurance that provided coverage.
Access to dental insurance was later organized under the same model as the health maintenance organization (HMO) model, which requires an insured to choose a single primary care doctor who controls access to all other medical specialists and services. DMOs cover a broader range of dental services, but the insured must choose a primary care dentist at the start of the policy. After making this decision, the insured must first visit his PCD, even if the service he requires will be provided a different dentist.
There are two types of dentists: generalists and specialists. Basic dental care, such as cleanings and fillings, is provided generalists. Specialists perform major dental procedures such as bridgework, tooth extraction, and braces installation. Dentists who provide primary care can only be generalists. A PCD cannot be chosen from the specialist category an insured.
Insurance companies expect a primary care dentist to keep track of how many services are used so that insurance costs don’t get out of hand. The theory is that requiring the insured to take an extra step and obtain an independent assessment of the procedure’s need will prevent overuse. PCDs also serve as a point of integration, storing the insured’s complete dental record, including all specialist reports. This should, in theory, improve the quality of care because no dental decision is made in a vacuum.
Finally, insurance companies argue that treating services as a gateway reduces costs, allowing them to provide more comprehensive dental coverage. The additional time it takes to obtain the services that are actually needed, as well as the multiple co-payments that must be made with each additional office visit, are some of the disadvantages to the insured. A co-payment is an out-of-pocket expense that insurance companies require insureds to pay each time they visit the doctor’s office.