Bupa Platinum Dental Provider

Smile Solutions is a Bupa Members First Platinum dental provider in the Melbourne CBD.

This page explains what that arrangement covers, and — more usefully — what preferred provider status actually is, because it is one of the most misunderstood things in Australian dentistry and it is regularly mistaken for a quality rating. It is not one.

What eligible Bupa Members First Platinum members receive

No out-of-pocket cost for routine preventive dental care, which includes:

• Consultations and dental examinations
• Scale and clean
• Bitewing radiographs
• Fluoride treatments
• Mouthguards

Between 60% and 100% rebate on most other dental services, depending on the item and the level of cover.

Children may receive a full rebate on dental services, again depending on the level of cover held.

Eligibility

• You must hold hospital cover combined with extras cover that includes general dental. Extras-only policies and hospital-only policies do not qualify.
• Bring your Bupa card to the appointment so the claim can be processed on the spot.
• Annual limits, sub-limits, waiting periods and policy restrictions apply, and they are set by Bupa, not by the practice.

Confirm your own cover directly with Bupa before booking. The practice can see what a health fund terminal returns; it cannot see your policy.

What ‘preferred provider’ actually means

A commercial agreement between a practice and a health fund. The practice agrees to charge no more than a schedule of fees the fund sets, for a defined list of items. In return, the fund pays a higher rebate — often the full fee for preventive items — and lists the practice in its provider search.

That is the whole mechanism. Three consequences follow, and all three are worth knowing:

1. It is not a quality accreditation. No fund assesses clinical outcomes to award preferred provider status. The register that says something about a clinician's qualifications is at ahpra.gov.au, and it is free. What an award or a badge does and does not tell you is a closely related question.

2. Preferred provider fees are a discounted schedule, not the practice's own fees. This is why Packages & Offers states plainly that its packages do not apply to patients treated under preferred provider schemes — you cannot claim a discounted package fee and a fund-negotiated fee for the same item. Ask which basis applies to you before treatment.

3. ‘No gap' applies to specific items only, and usually only preventive ones. A no-gap check-up does not mean a no-gap crown. The gap on major work can be substantial, and it is where almost every billing surprise originates.

The rule that matters more than any of it

Which fund you belong to should not change what treatment you are told you need.

Advertising and conduct rules for registered health practitioners in Australia — including section 133 of the National Law — prohibit encouraging the indiscriminate or unnecessary use of health services. Clinical need is determined by examination and diagnosis. A rebate determines what you pay, never what you need.

Two practical tests:

• If a treatment plan changes materially once you mention your fund, ask why, in writing — and a second opinion is a reasonable next step.
• If you are told to have something ‘because your limit resets', that is a financial argument being presented as a clinical one. Unused annual limits are not a reason to have dentistry. They are a reason to have the dentistry you actually need, sooner rather than later — which is a different sentence.

Conversely: if you need treatment and your limit is exhausted, the right answer is usually to sequence the work across two benefit years, not to skip it. Ask for that conversation explicitly.

How Australian dental rebates actually work

Because almost nobody is told this:

• Private health insurance dental benefits are not proportional to the fee in any simple way. Funds pay a set benefit per ADA/ASDS item number, or a percentage capped at a maximum. The item number — not the description — determines the rebate.
• Ask for a written quote with item numbers, then phone your fund and read them out. This is the only reliable way to know your gap in advance, and it takes about five minutes.
• Annual limits are per person, per calendar year, usually resetting 1 January, and typically split between general and major dental.
• Waiting periods apply to new policies and to upgrades — commonly two months for general dental and twelve months for major dental.
• Preventive care is the item funds cover most generously, everywhere, because it costs them the least. That incentive happens to align with good dentistry, which is not always the case elsewhere in the system.
• There is no Medicare rebate for general adult dental treatment. The main exceptions are the Child Dental Benefits Schedule for eligible children and state public dental services for eligible concession card holders. Price Guide covers this.

Why a gap exists at all: what an independent fee survey shows

A benefit schedule and the cost of providing treatment are two different numbers, and nobody in the system pretends otherwise.

The Australian Dental Association's Dental Fees Survey 2022 — drawn from 3,819 valid responses, most of them general practitioners — found that across the 122 items surveyed, fees charged by general practitioners “appear to have increased by 3.7% during the two-year period since 1 July 2020”. Within that average, the smallest increases were in Preventive Services and Periodontics (1.6%) and the largest in Orthodontics (6.9%).

More useful than the average is the spread. The survey reported “considerable variation in the fees charged within and between states” — on average the lowest fees in South Australia and Western Australia, the highest in the ACT and the Northern Territory, though the ADA cautions that the small sample in those two jurisdictions means their results “should be viewed with caution”.

And the ADA says out loud what the gap is for. Its stated purpose for the survey is to support advocacy on “closing the gap between benefits schedules used for the CDBS and Veterans Affairs dental schemes, and the actual costs of providing treatment under these schemes.” A schedule is a payer's number, not a cost. That is true of a government scheme and it is true of a private fund's preferred provider schedule — which is why the practical advice on this page is always get the item numbers and ring your fund, not assume the schedule covers it.

(Source: Australian Dental Association, Dental Fees Survey 2022.)

For children: what the Child Dental Benefits Schedule does and does not cover

This is the one Medicare-funded dental benefit most families are entitled to and many never claim.

Services Australia states that the CDBS covers up to $1,158 for each eligible child over two consecutive calendar years for basic dental services, and that “the cap amount is indexed yearly on 1 January”, with an increase applying only to a child who received their first eligible service in that calendar year. An earlier period carried a lower cap of $1,095, so a figure quoted elsewhere is not necessarily wrong — check which period it describes.

Covered: check-ups, X-rays, cleaning, fissure sealing, fillings, root canals and extractions. There are item and time restrictions, and Services Australia advises checking with your dentist before treatment starts.

Not covered, in full: orthodontic dental work, cosmetic dental work, and any dental services in a hospital.

Three details that cost families money:

• The two-year period starts at the beginning of the calendar year in which the child both becomes eligible and receives their first dental service.
• Unused benefit does not roll on. If the full amount is not used within the two calendar years, “you can’t use the remaining funds” — you wait for a new cover period. Entitlement also ends if the child stops being eligible.
• CDBS services do not count towards the threshold of the Medicare Safety Net or the Extended Medicare Safety Net.

How the Child Dental Benefits Schedule operates covers the mechanics, and the practice's CDBS page covers claiming here.

(Source: Services Australia, Child Dental Benefits Schedule; What's covered by the Child Dental Benefits Schedule.)

If something goes wrong with a claim

• Start with the fund. Most disputes are item-number mismatches and are resolved on the phone.
• The Private Health Insurance Ombudsman handles complaints about health funds, independently and free of charge.
• The practice can reissue an account with item numbers if your fund needs it in a particular form.
• For a concern about clinical care rather than billing, the Victorian complaints body is the Health Complaints Commissioner, and the national regulator is AHPRA. How to raise it, and with whom.

Booking

Phone 13 13 96 or email theteam@smilesolutions.com.au. Say you are a Bupa Members First Platinum member when you book, so the right fee basis is applied from the start.

Common questions

Do I have to tell the practice which fund I am with?

You do not have to, and there is a real argument on both sides — so here is both, rather than only the convenient half.

The case for telling us: the claim can be processed on the spot through the terminal, the correct fee basis is applied from the start rather than corrected afterwards, and you find out your gap before you commit rather than at the counter. That is the practical reason this page asks you to bring your card.

The case for caution is made most directly in a consumer submission to the federal parliamentary inquiry into the value and affordability of private health insurance and out-of-pocket medical costs (Submission 265, The Dental Consumer Perspective, 2017). Its author argues that fund membership details are unnecessarily collected and stored on new-patient forms, and describes a personal experience of a plan expanding once fund status was disclosed. The same submission asks the committee to examine privacy around terminal-based claiming, noting the Productivity Commission's Data Availability and Use draft report cited the ADA's comment that some insurers which operate dental practices may have access to the identity of patients treated through those terminals.

That is one consumer's submission to an inquiry, not a finding. We include it because the concern it names is the same one this page addresses above, and because a patient is entitled to know the argument exists.

Where that leaves you, practically:

• You can decline to give fund details and pay the account yourself, then claim from your fund afterwards. It is slower and it is entirely your right.
• If you do disclose it, apply the two tests set out above — did the plan change when the fund was mentioned, and is anyone arguing from your limit rather than from your mouth?
• Ask for the plan and the diagnosis before any discussion of rebates. The order of that conversation tells you a great deal.

I am with a different fund, or with no fund at all. Can I still come here?

Yes. A preferred provider agreement is a fee arrangement with one insurer. It is not a restriction on who may be treated, and it is not a statement that other patients are less welcome.

What changes is the arithmetic, not the access:

• With another fund, you are quoted the practice's own fees and your fund pays whatever benefit it sets for those item numbers. That benefit may be generous or it may not — it depends on your policy, and the method for finding out is the same one described above: get the itemised quote and read the numbers to your fund.
• With no fund, you pay the practice's fees, and the published fixed-price items and the price guide are the place to start. Payment plans exist for larger totals, on the terms set out there.
• Either way the clinical part is identical. The rebate is a payment arrangement; it is not a treatment pathway.

One thing worth knowing about fund provider searches. A listing in one is a commercial arrangement, not a ranking. The Australian Dental Association's own fee survey found “considerable variation in the fees charged within and between states”, which means the cheapest quote and the best-value quote are not reliably the same document. Compare itemised quotes with item numbers, and check what each includes.

Is extras cover actually worth it?

This page cannot answer that for you, and any dental practice that tells you it can is guessing about a policy it has not read.

What it can do is tell you how to work it out, because the sum is simpler than it looks:

1. What you pay in a year for the extras component of your premium.
2. What you actually claimed last year — not what you could theoretically have claimed. Your fund will give you this.
3. Your annual limit and its sub-limits, and whether you have ever reached them.
4. What is excluded or waiting, particularly major dental, which commonly carries a twelve-month wait.

If 2 is consistently well below 1, the cover is not paying for itself on dental alone. If your household has children in orthodontics or an adult in a long restorative plan, the answer usually runs the other way.

The broader argument is live and worth knowing about. The consumer submission cited above predicted that patients with private health insurance “may also increasingly quit due to rising fees and diminishing value for money for ‘extras cover' (dental items)”, and noted that there is no public body to which patients can complain about the level of dental fees themselves — as distinct from the Private Health Insurance Ombudsman, which does handle complaints about funds, free and independently. Again: that is a submission's argument, not an established finding.

The part that is not in dispute is that preventive items are the most generously covered, everywhere. If you hold extras cover and are not using the check-ups and cleans it pays for, that is the clearest waste in the whole arrangement.

Why is dentistry outside Medicare, and is anything changing?

It is a long-running policy question rather than an oversight, and it is being actively argued from several directions. We set it out because it explains almost every frustration on this page.

What is settled: there is no Medicare rebate for general adult dental treatment in Australia. The exceptions are the Child Dental Benefits Schedule for eligible children, veterans' schemes, and state public dental services for eligible concession card holders — the last of which, as the contact page notes, reaches around a quarter of Australians and carries waiting lists.

What is argued:

• The ADA's position, stated as the purpose of its own fee survey, is that there is a gap “between benefits schedules used for the CDBS and Veterans Affairs dental schemes, and the actual costs of providing treatment under these schemes” — that is, that the existing public schedules pay below cost.
• The consumer submission cited above argues the opposite end of the same problem: that the absence of any national dental fee schedule leaves patients with no consumer guidelines by which to judge whether a fee is reasonable, that patients can obtain conflicting diagnoses and widely varying quotes, and that rural and regional patients are worst affected because insurer-owned clinics and preferred providers cluster in major cities. It proposes a recommended, non-mandatory schedule of the kind published by the Australian Medical Association and the Australian Psychological Society.
• The cost of the gap is measurable. That submission cites an Australian Institute of Health and Welfare survey finding that nearly a third of people aged five or older — 32% — avoided or delayed visiting a dentist because of the cost.

What it means for you today: until something changes, the item number and the phone call to your fund are the only tools that give you certainty before treatment. That is an unsatisfying answer to an unsatisfying situation, and it is the honest one.

Related pages: Price Guide, Payment Plans, Packages & Offers, Our Services, Children's Dentistry, Understanding Your Treatment, Contact Us.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment.

This page contains general information, not clinical or financial advice. Cover, rebates, limits and waiting periods are set by Bupa and change; the current terms of your policy are the ones that apply, and they should be confirmed with Bupa directly. Eligibility is determined by your policy, not by this practice. Child Dental Benefits Schedule amounts, eligibility rules and covered services are set by the Australian Government and change — the figures above are as published by Services Australia and should be confirmed with Services Australia before you rely on them. Fee survey figures are attributed to the Australian Dental Association and describe fees charged by surveyed ADA members nationally; they are not this practice's fees. Material attributed to a submission to a parliamentary inquiry represents the view of that submission's author and is identified as such; it is not a finding of the inquiry, of this practice, or of any regulator.

Smile Solutions trades under ABN 28 193 514 103.