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Advice regarding new contracting for DHMOs as a part of a State Benefi

Guest bbruno

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We are going into a bid cycle for our plans. Our concern is to get the most bang for the buck, especially in quality and services provided by dental providers to member employees. Because we are not self-funded but insured, the desire is to create performance standards for the contracting plans to be held accountable for in the quality of benefits provided under this type of plan and access to providers. The thought is what kinds of performance standards might be reasonable and useful with a DHMO and how effective the use fo financial penalties would be based on quality assessments made based on employee survey results (e.g., survey results obtained by the plan vs. those obtained by the administrator), or if it is even feasible to do so. As DHMOs tend to run on slimmer operating margins, financial penalties may or may not be a feasible alternative based on survey results from employees, as an example- so, looking for any advise, history or comments on this matter. Any comments or ideas would be appreciated.

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  • 4 weeks later...

Performance guarantees for DHMOs are more difficult than those of PPO or indemnity plans. We have had guarantees in place for the last 4 years for both the DHMO and the indemnity plan - with the same carrier. Various factors put a percentage of their admin fees at risk (.5% to 1.5%). The total at risk is 6% of their fees.

The DHMO factors were:

1. Satisfactory implementation by XX date.

All communication materials deliverly timely.

All vendor rep attended any and all meetings including

employee meetings.

Receipt of final contract by XX date.

2. Satisfactory service to HR personnel, including:

90-day response to any and all unsatisfactory service complaints by HR.

Standard reports, returning of phone calls,etc.

3. Network development and directory maintenance

4. Customer service - phone call response times avg XX seconds and abandonment rate of less than XX%. Satisfactory results of annual member survey with 95% satisfaction rating.

5. Enrollment/Eligibility including accuracy and timeliness of ID cards and eligibility updates

Some factors take more time to monitor than others. We frequently disagree with whether the standard was met or not. However, we found that the main purpose of the performance guarantees was to keep the vendor from getting too relaxed in their day-to-day service.

Hope this help you.

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