A primary care dentist (PCD) is the principal dental care provider for an insured patient under a dental maintenance organization (DMO) insurance plan. This dentist is responsible for coordinating and integrating dental care for the patient. The PCD serves as a gateway to dental specialists. Insured patients under this sort of dental plan must obtain a referral from their primary care dentist before they can visit a specialist. This approach may keep dental costs lower for patients and insurance companies, while allowing access to a wider scope of services and better quality care.
Traditionally, dental insurance options were meager. The most common type of insurance offered was for basic dental maintenance, such as cleanings and cavity fillings. Major dental work was often not covered. Only those dental policies that were integrated with medical insurance covered more complex procedures, such as getting braces. In both instances, however, the insured had direct access to any dental generalist or specialist by simply calling and making an appointment with a practitioner who accepted the type of insurance providing coverage.
As a result of the popularity of the health maintenance organization (HMO) model of requiring an insured to select a single primary care doctor who controls access to all other medical specialists and services, access to dental insurance was later organized under the same model. DMOs offer a wider array of covered dental services but require the insured to select a primary care dentist at the outset of the policy. Once this selection is made, the insured must go to his PCD first, even if the service he needs will be provided by a different dentist.
Dentists fall into two categories: generalists and specialists. Generalists provide basic care, such as cleanings and fillings. Specialists do major dental work, such as bridgework, pulling teeth and installing braces. Primary care dentists can only be generalists. An insured cannot pick a PCD from the specialist category.
Insurance companies expect a primary care dentist to control the use of services, so insurance costs do not spiral out of control. The theory is if the insured has to take an additional step and get an independent assessment of the need for the procedure, it will prevent overuse. PCDs also serve as a point of integration, maintaining the insured entire dental record from the reports of all specialists. Theoretically, this should improve the quality of care, since no dental decision would be made in a vacuum.
Ultimately, insurance companies argue that this gateway approach to services controls costs, which in turn allows them to offer more comprehensive dental coverage. Some of the drawbacks to the insured are the additional amount of time it takes to obtain the services that are actually needed and the multiple co-payments that must be made with every additional office visit. A co-payment is the out-of-pocket contribution that insurance companies require insureds to pay whenever they make an office visit.
