Health Funds & Preferred Providers

The affiliation between dentists and private health funds is primarily through preferred provider agreements. Although patients are told by their health fund that such an agreement allows the health funds(them) to reimburse a percentage of the costs for dental services provided by certain dentists/practices, please note that the percentage that the specific private health funds will “cover” or “rebate” depends on the member’s level of cover as well as what health fund they are with. 

This is rarely a reasonable % of the full price per code (item) and is usually a set fee that the private health fund will agree to re-imburse the dentist (practice). This arrangement can lead to a lower out-of-pocket “gap” for the patient. This of course is the appeal for patients; however, it is essential to compare the quality of care with the alleged financial benefits to ensure the best value for dental care.

We are not insinuating that all financially beneficial arrangements (for patients) come at a decreased quality of care, however these losses financially for practices need to be made up in some way. Usually, it means time allocations are less, inferior products might be bought...

The main issues Family Dental Yamba and Grafton’s owners Dr Aninke Lippert and Dr Willem Espag have with most preferred provider agreements are that:

1. Patients are steered towards practices based on whether they are affiliated with the health fund and not because of the clinician’ reputations and their skill set. It means that the health funds basically determine who they are “recommending” their members to see. It isn’t directly, rather indirectly and patients are usually not aware of this.

2. It forces the practices into set fees that aren’t increased with inflation and not necessarily when their premiums go up as a member. That means that practices may struggle to break even over time.

3. Agreements with private health funds limit practices’ independence and are certainly not in the patient’s best interest. The ones who benefit mostly are the private health funds as preferred provider agreements generate profit for them.

4. Our Australian Dental Association (ADA) has recommended over the years for clinicians to steer clear of agreements like these as it affects patients’ clinical choices and lowers the standard of care.

5. Health fund increases in premiums are not matched to comparable increases in rebates , fees or membership benefits. A common “non-for profit” health fund recently decreased their members’ benefits despite and increase in their premium costs. This happens more often than patients realise.

So, in short: We have tried to stay clear of being affiliated with private health funds since our practices opened in 2015. We believe that it is in a patient’s best interest to be looked after by independent dentists.

We will continue to provide you with a full range of treatment options, quality dental care with state-of-the-art equipment and the highest quality materials we can find. Our aim has always been to serve our community with integrity, authenticity and kindness. We will continue to strive to build life-long relationships with your whole family. At our practices you will be made part of the decision-making process and given all the information you need to make informed decisions that suit you and your circumstances. Our patients know that we care and value their oral health, usually even more than they do themselves.

We strongly suggest you contact your private health fund personally. As most ‘non-for-profit” health funds, they still make a considerable profit. As a member it is up to you to ask them how you are benefitting. We personally do not see that these funds are ploughing the “profits” back to their members. If anything, we continue to see: less item numbers being covered, the amount of coverage being less per item, premiums for members going up and more restrictions being placed on members as to where these minimally out of pockets will apply.  

We recommend you base your private health insurance and level of cover on what you need from them, and that may include or exclude dental cover. Most health funds have a differentiation between major dental cover and general dental. Depending on your needs, this will usually determine what level of cover you may choose. This type of decision is something we stay well clear of as this is an individual patient decision. It is not in your best interests to have a health find nominate who you should see for your dental needs. Such “recommendations” are not based on clinical experience, best practice, standards of care or technology.

If you are after unbiased, objective comparisons and information, the following website might be helpful to you: www.privatehealth.gov.au

Kind regards

Dr Willem Espag and Dr Aninke Lippert