EPO - Limited Practitioners for Best Service?

One of the dental insurance options out there is an exclusive provider organization, or EPO. EPO health care plans can be an affordable option to pay for your dental needs, but it is important that you understand the details about EPO network coverage.

What is EPO?

EPO stands for exclusive provider organization. A dental EPO is a network of dentists that are partnered with the insurance company to provide care at a reduced cost. In return, the EPO pays most of the cost of the customer's health care needs. An EPO is a closed dental plan, which means that customers can only visit the doctors that are in the plan.

EPO and HMO

Exclusive provider organization and HMO plans are somewhat similar. They are similar in that they both restrict the number of dentist their customers have to choose from. They are also similar in that access to certain types of dental care can be restricted in both types of plans. Unlike an HMO, EPO does not pay the dentist until they perform services for the customers. HMOs will pay the dentist monthly for all of the customers in the plan.

What is Covered Under EPO Plans?

EPO health care plans cover expenses when their customers see dentists that are a part of the EPO network. Exclusive provider organization plans are considered closed panel plans. This means that only the dentists who signed a contract with the insurance organization are qualified to give care to the customers of the EPO. Sometimes emergency services for out of network providers are covered, but this is a rare exception to the rule. If a patient who has an EPO dental plan wants to see a dentist who is not in the network, the patient will pay out of pocket for all of the expenses of that particular dental visit.

What Services are Not Covered

Your exclusive service provider may limit the types of specialized services you have access to. This is perhaps due to the fact that specialized services are quite a bit more expensive than traditional dental services. Also, EPO drugs th at are covered may not be all the possible drugs you need to treat your dental needs. When choosing an EPO network, make sure enough services are provided. Experimental dental treatments are almost never covered under EPO plans.

Some Dentists Choose not to Use EPO

Sometimes, high quality dentists choose not to participate in EPO networks. This is because the EPO will require the dentist to reduce the fees they charge for their services for patients that are part of the EPO. Many dentists who have a large clientele base will decide that the increase in customers from joining an EPO is not worth the reductions in cost. Often, these are the more qualified dentists who have a significant number of patients already. Another interesting thing that you might find when joining an EPO plan is that some of the dentists in the plan may actually be salaried employees of the exclusive provider organization that they are a part of.

Submitting a Claim

Each EPO will have a different process for submittin g claims. The dentist may be required to submit the claim, or the patient may be required. It is important that claims are submitted in a timely manner, to ensure that the dentist is paid promptly, and collections actions do not get set in place. Claims are sent to the claims address of the EPO. Your dentist may choose to take care of this with their office so that they ensure that they get paid.

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