Understanding Dental Insurance
By Dr. Presley-Nelson
Should you get dental insurance? Is the insurance you have adequate? There are many questions concerning dental insurance. Insurance companies are in the business of making money by keeping as much of what you pay them in premiums and, in turn, trying to pay providers (like our dental office) as little per procedure as possible. This is why dental plans have such low annual maximums and often unrealistically prohibitive policies on procedures they cover.
For example, some plans won’t pay for white fillings on back teeth, even though tooth-colored fillings are what most people want. Some insurance companies only cover silver fillings and make it the patient’s responsibility to cover the difference. Another relatively new policy becoming more common in dental insurance plans is to cover a crown once every 10 years. So many things can happen to a crown as the result of normal wear and tear that this almost guarantees that in most cases, the insurance company will not help the patient with the cost of any replacement crowns.
Our priority is patient care. We recommend ideal treatment, and your well-being is our central focus. Of course, we realize that financial concerns are a reality, which is why we try to be sensitive to insurance plan limitations and policies. However, we can’t in good conscience treat you based on insurance coverage if it isn’t in your best interest. Having said that, let’s start with some terms you need to know.
ANNUAL MAXIMUM is an amount that an insurance company will pay out for your care in a given year. The plan your employer or you picked will have an Annual Maximum. This is different from most medical insurance, which will kick in when catastrophe hits. Dental insurance is different. No matter what happens to your teeth, it will only cover up to a specified amount. Many policies have not raised this maximum since the 1970s and still cover only $1000 a year. So how does your dental plan measure up? Check and see if your yearly premium payment is less than the annual maximum. Also check and see if your yearly premium is less than or equal to your yearly cleanings and check-ups, with some left over in your maximum, in case you break a tooth or need any kind of work. If not, then consider insuring yourself by saving that amount in a “dental account” and drawing interest on it instead of someone else drawing the interest. OR approach your employer about Direct Reimbursement, where they cut the middle-man, and contribute a set amount to your dental care. Ask us for a pamphlet about this.
Another term you need to know is USUAL, CUSTOMARY AND REASONABLE (UCR). These are fees that an insurance company creates so they can limit the amount they pay on a specific procedure, even if you still haven’t used your maximum. These fees have nothing to do with what it costs a dental practice to do business, and are usually general to the whole country, not keeping in mind the cost of living in certain parts of the nation. Check and see if your plan’s UCR is much lower than our very reasonable fees. If so, then your insurance company is making the payment of the difference in your responsibility.
PPO is a PREFERRED PROVIDER ORGANIZATION. This is a way insurance companies can pay out less by getting dentists to join, in the promise of being sent patients, if they sign a contract for lower fees. An HMO is a Health Maintenance Organization which, like a PPO, entices dentists to join, but does so by sending a check each month per patient or family (sometimes only about 5 dollars or so) whether the patients come in or not. Since no treatment can be delivered for the tiny monthly amount, the dentist discourages appointments, delays treatment, or keeps a long waiting list, hoping the patients will give up and not come in. Both PPOs and HMOs encourage high volume and rapid, brief care. We strive to deliver high quality, very personal care, and so have tried not to join many PPOs and no HMOs. If we did, you would see us rushing through many more patients and spending much less time with you. Market pressures have had us join only a few of the better quality PPOs such as Delta Premier (which is a PPO even though they offer a cheaper plan they call Delta PPO), DeCare, and Cigna DPPO. These cause us numerous difficulties, but we are trying to work with them as their forced fee schedule is slightly less punitive than others.
Recent Affordable Care Act (Obamacare) changes have caused many of our patients’ employers to have increased medical insurance costs. To compensate for this increased cost, many have lessened dental coverage by only offering HMO or lesser PPO alternatives. Please forgive us if we do not “join” these and therefore have to compromise our services. WE STILL TAKE ALL INSURANCE whether we are in-network or not. Because we try to keep our fees reasonable, often the out-of-network difference in what the patients pay is small. We want to keep you all as patients and will always strive to perform to our outstanding standard for each and every one of you.