The aim of this Policy Statement is to review the current status and define the role of the Third Party and the principles through which it can support to the best possible oral healthcare and healthcare outcome for the patient without compromising the dentist’s ethical obligations and patients’ right to choose their treatment in consultation with the dentist of their choice.
Third Party Payer (TPP)
Any organization, public or private, that pays or contributes for healthcare expenses, on behalf of beneficiaries, such as employers, commercial insurance companies and public health funding mechanisms. These payments, called third-party payments, are distinguished by the separation between the individual receiving the service (the first party), the dentist providing the service (the second party), and the organization paying for it (the third party)1.
The conditions, rules and regulations governing the existence or non-existence of TPPs, as well as the way they operate, vary from country to country. It is important for TPPs to be appropriately involved in healthcare funding where they can provide a solid foundation for a safe and quality-oriented healthcare system without interfering with the dentist’s professional treatment decisions or the patient-dentist relationship.
- TPPs are a source of full or partial payment for dental treatments or dental non-clinical work rendered.
- Their financial involvement should support appropriate oral healthcare for the patient and evidence-based treatment decisions agreed upon by the dentist and the patient, rather than by benefit protocols, leading to a positive impact on the dentist-patient relationship.
- TPPs are responsible to provide clarity to patients as to the scope of coverage of their contracts and the terms attached to the provision of treatments covered.
- Patients should receive necessary treatments, and the plans should pay fairly and promptly, to reduce or eliminate patient’s out of pocket expenses. However, the patient should remain responsible for the payment to the dentist if the TPPs fail to pay.
- Dentists contracted to a TPP as a “panel dentist” or a “non-panel” dentist should receive fair payment.
- The TPPs, public or private, should compensate fairly for treatment provided by the dentist, and be in the best interest of the patient.
- The contracts between the TPPs and the panel dentist should be reviewable and adjustable on a regular basis agreed upon.
- TPPs involvement in adjudicating claims should respect the treatment decisions made by both by the dentist and the patient, facilitate a positive dentist-patient relationship and allow the patient to receive the best possible care in confidentiality and anonymity.
The information in this Policy Statement was based on the best scientific evidence available at the time. It may be interpreted to reflect prevailing cultural sensitivities and socio-economic constraints.
Healthcare funding, Dental practice, Third parties, Dental benefits, Compensation, Dental Plans
- American Health Lawyers Association. Definition from ’Health Law Resources’, specifically ’Terminology, in FUNDAMENTALS OF HEALTH 58 LAW 1, 42. (https://www.healthlawyers.org/Pages/home.aspx, accessed on __ _____ 2017).