Reimbursement and Business Plans

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Summary

The delivery of oral health care to an aging population has many challenges, none greater than how to pay for that care. Lack of financial resources has created a significant barrier resulting in blocked access to care for the majority of our nation's elderly. Dental funding for Medicare and Medicaid state programs is grossly lacking or nonexistent. Many nursing facilities are faced with ever-tightening budgets due to recent Medicaid cuts compromising expansion of programs and services. Aging baby boomers have made little effort to ensure financial solvency for their golden years. This will leave many dependent upon financially burdened state entitlement programs. When financial resources are not available, the dentist is placed in the unfortunate position of making treatment-planning decisions that compromise optimal patient care. The reluctance of dentists to take on uncompensated care burdens is understood when examining basic dental practice management principles.

Historically, payment for dental services has been quite varied. Self-pay and dental insurance have proven to be the nation's strongest payer sources for the population at large but are often the least available payment source when individuals are confined to long-term care facilities. The Omnibus Reconciliation Act of 1987 overhauled the nation's long-term care industry but did little to ensure that financial resources were in place to meet the oral health care needs of older Americans. Adequate financial resources are a key factor in sustaining and providing quality dental care in long-term care settings. A thorough understanding of the strengths and weaknesses of various payer sources and creative strategies for building financial partnerships with nursing home facilities is critical to financial success.

Successful business models are developed from well-thought-out business plans. The business plan is a cornerstone for determining successful financial strategies to ensure business model solvency. Basic business plan components include objectives, market conditions, benchmarks, program design, financial analysis, risks and expectations. Each component is critical and interdependent, which creates a document to guide and evaluate the business endeavor. A well-implemented business plan will guide the dentist in program development and outcome measures.

Despite limited financial resources to support oral health care services in long-term care facilities, there are a number of financially successful programs nationwide. Three successful delivery models will be reviewed. Each model has successfully integrated various payer mixes to define scope of services, patient volumes and contract fees to maintain positive revenues above expenses. The leadership, operational and financial strengths and weaknesses of each program will be identified and hopefully found useful for existing or new start-up programs. Dental practitioners can experience financial solvency if they understand the critical elements of financial reimbursement. The presentation "Geriatric Oral Health Services/Critical Elements for Maximizing Reimbursement" will offer the course participant an opportunity to explore practice management principles and strategies to improve financial stability of their nursing home programs.