DENTAL INSURANCE

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THERE ARE 3 TYPES OF DENTAL INSURANCE

There are three main types of dental insurance.

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1. Indemnity Insurance:                                                                                         

   • Does not limit you to a list of providers ​

   • Does not offer any type of incentive for using a certain provider/s 

   • Your choice of dentist will have no effect on how your procedures will be covered 

   • Most plans will cover any fees that your dentist may charge                                 

   • For these reasons, this Indemnity insurance is the most popular preferred choice of insurance plan.                                                                                                             Indemnity insurance does not limit you to a list of providers. Indemnity insurance does not offer any type of incentive for using a certain provider/s.   Under Indemnity insurance, your choice of dentist will have no effect on how your procedures will be covered. Most indemnity plans will cover any fees that your dentist may charge. For these reasons, this Indemnity insurance is the most popular preferred choice of insurance plan.                                                                                                                 In other words, you can choose your dentist and it will have no effect on how your procedures are covered.   In this respect, you could argue that this type of insurance is preferable.   Most indemnity plans will pay the fees that the dentists charge.    

2. Preferred Provider Organization (PPO):                                                         

   • Does not limit you to a list of providers ​

   • There is a financial incentive to select a dentist from the insurance's list of participating dentists

   • Not all PPO plans are the same.   Some have fee schedules that are close to average local fees and also have reasonable clauses.   Others are more limiting.

   • offices accepting PPO's will likely also accept Indemnity insurance plans, or cash                                                                                           Preferred Provider Organization (PPO):                                                                                                                                                        PPO insurance plans do not limit who you can see. However, there is a financial incentive if you see someone from their list of participating dentists.  Here is how this works.   An insurance company will create a plan with a set of predetermined fees and clauses.   These fees are often less than the average fees charged by dentists in a geographical area.   Some dentists will decide to not participate with these plans if they feel that they will not profit sufficiently without altering their way of practicing.  i.e. (going faster, compromising quality, pushing for more expensive treatment plan options, limiting staff wages, etc.)   Other dentists will sign up with one or more of these PPO plans if they feel that they can profit and still work in a fashion that meets with their standards.   The incentive for dentists to sign up with a PPO plan is that the plan will suggest to the dentist that by being on a list, they will receive more patients.   Certainly there are established dental offices that run profitably on PPO plans.   Many newer practices will sign up with PPO plans when they do not have an established patient base.   As those practices become more mature, some of them may drop the least profitable plans.   Others will drop all of the plans.   And yet others will keep all of the plans if they have developed systems that work profitably within the PPO guidelines.  Some towns or areas are so inundated with businesses that have contracted with PPO plans that it would be difficult to run a dental practice in those areas if they did not participate.   Again, dental offices must decide if they can achieve a balance with expenses (rent, salaries, supplies, utilities) and a reduced fee schedule.  Not all PPO plans are the same.   Some have fee schedules that are close to average local fees and also have reasonable clauses.   Others are more limiting.  I believe that all offices that have one or many PPOs will accept indemnity plans as well as cash paying patients.

3. Dental Maintenance Organization (DMO):   ​ 

   • Different from both Indemnity and PPO insurance plans

   • You pay a monthly fee that covers a certain level of dental care                      (Ex. a dental exam, a set number of teeth cleaning appointments, necessary dental x-rays, and simple fillings)   

   • Any additional dental work must be payed for out of pocket                While this might sound bad, one could argue that more expensive procedures might have more profit for any dentist in any insurance model, as well as with cash paying patients.

Dental Maintenance Organization (DMO):   ​                                              Although I have never participated in a DMO, I believe that DMOs work in the following way.   A dentist will agree to accept a certain monthly fee for each patient.   In return for that fee, the dentist will agree to perform a certain level of dental care.   For example, this agreed upon care might include a dental exam and cleaning twice a year, necessary dental x-rays once a year and simple fillings.   In cases like these, the dentist might actually profit more if the patients did not come in often or if they did not need any fillings.   The dentists may be allowed to “upsell”.   In other words, there might not be an “out of pocket” cost to the patient for fillings but if they needed the more expensive crowns, the patients might have to pay for some or all of those fees and there might be a financial advantage for dentists to do these more expensive procedures.   While this might sound bad, one could argue that more expensive procedures might have more profit for any dentist in any insurance model, as well as with cash paying patients.

Does dental insurance pay 100% of my dental needs?

Should dental insurance pay 100% of my dental needs?

 

Many patients who are experiencing having dental coverage for the first time might have the expectation that dental insurance means that all of their dental needs will be covered.  That is almost never the case as the more complete coverage a plan has, the more it will cost the employer.  Some employers will offer better plans because they can afford to do that and because they feel that this will be appreciated by their employees.   Other employers will offer lesser plans in the hope that employees will appreciate any plan but the employer wants to limit their financial burden.   As a dentist, I have felt the disappointment from some patients as my team reveals to them the nature of their insurance and their estimated patient portion.  I wonder how much of their disappointment is toward their insurance carrier or their employer.  It feels like the disappointment is directed toward the dental provider.  My suggestion for those disappointed with their dental insurance coverage is to bring it up with their employer.  The sky's the limit with what insurance companies can offer but there would be more cost to the employer.   If enough people approached the employer with the same requests, perhaps the employer would upgrade the coverage.   

 

Because I have always had a healthy mix of insured and cash paying patients, I have noticed that the happiest patients appreciate the help that they receive from their insurance but are not disappointed that not everything is covered.   In addition, I feel that ideally, people should make decisions for their dental care based on their health and modified by their financial means.  I feel that it can be a mistake to base dental care on insurance coverage alone.   In the long run, this can be devastating.   I have seen a simple filling put off into the future in order to wait for more coverage only to worsen to the point of needing a root canal and crown.   

 

The best way to decide what your needs are and what is the best plan of action taking everything into account is to establish a trusting relationship with your dentist and form a dentist/patient team and not a dentist/patient opponent.  

 

Who is responsible to pay for dental fees when an insurance company does not pay?

 

When a patient agrees to have a procedure, it is understood that the dentist should be compensated their fee.   Certainly cash paying patients will pay their fee.   Despite the best efforts from dental offices to estimate what an insurance company will pay for a given procedure, sometimes the insurance company will not act as predicted.   Even when a dental office submits the treatment proposal and fees in advance for a pre estimate, the insurance companies always state that the pre estimate is not a guarantee of payment.  The insurance company is a third party and not a part of the dental office nor do they work for the patient. They are in the business to make money as all businesses must be.  When problems with payment arise, dental offices might be able to re submit with additional information.   Ultimately though, the patient is responsible for the dentist’s fees.

 

Why did dental insurance begin?

 

As with all insurances, dental insurance began as a way to limit risk.   If your house burned down, the cost to rebuild could be catastrophic to your economic well being.   You might be more comfortable paying a certain amount for the assurance that in the event of a fire, you would be covered.  As a way to attract employees, some companies decided to offer dental insurance.   These businesses calculated the cost of the insurance versus the benefit of attracting and maintaining quality employees and decided that the benefit outweighed the expense.  Employees became savvy that a good “benefits package” was beneficial and valuable.   As time passed, the plans changed and became more complicated.   

 

What are some clauses to be aware of?   

 

Consider this a partial list.   In the late 1980s, dental insurances seemed to follow similar sets of payment considerations but since that time, many different factors to the plan contracts have changed or been added and things continue to change.

• Deductibles:  Some plans have a deductible if you receive treatment for anything other than preventive services (preventive services often include procedures like exams, x-rays and cleanings).   As an example, a plan could have a $50 deductible for the first procedure performed in a calendar year.

• Waiting periods:   Some plans could have waiting periods for the more expensive procedures.   As an example, “crowns and root canals are not a covered expense during the first year of coverage”.

• Fee schedules:   These are arbitrary fees set by insurance companies.

 

Why does my company have a certain plan?

 

Your company will choose a plan based on what they perceive is the best plan for the amount of money that they are willing to spend.

 

Which style of plan is the best for you?

 

The reality is that the amount of coverage and specific clauses may make a PPO (preferred provider organization) or a DMO (dental maintenance organization) option better for your situation. Every patient will have a unique dental situation and financial position.   If a patient has a lot of dental needs and is not as secure financially, then a plan that offers a higher yearly maximum dollar amount will be best.   Conceptually, if a dentist has higher fees they might be able to spend more time on a procedure, employ stable and talented staff, use the best labs and material, go to the best continuing education classes etc. etc.   This does not guarantee quality as there are very talented dentists accepting all styles of dentistry and it is possible that mediocre dentists might have higher fees.   But, in my opinion it is easier to do better dentistry when there are not tight time constraints.

 

Are there any good plans available for individuals?

 

Again this is a tricky question and the following is my opinion only. The way that insurance companies work well is when they contract with a large company or group.   As an example, a company with 1000 people will pay premiums on those 1000 people.   The insurance company knows the statistics that only a certain percentage of those 1000 people will actually go to the dentists and of those that do go, what percentage of people will have minor needs..   Because of this, the insurance companies know how much to charge a company and still make a profit.   

 

If an individual applies for insurance, the insurance companies will assume that this person has big needs.   There will be clauses like:  A one year waiting period to get a crown or dentures or, all procedures are on a fee schedule that has nothing to do with the dentist’s fees.   

 

In the end, for the insurance company to make money, they must pay out less than they take in so I have never seen a plan that made sense.   While I do not have any knowledge of this, it may be possible that some groups offer individuals to obtain insurance under a group plan.  

 

Why will some dental offices not bill my insurance for me?  

 

I suppose that all dental practices would prefer to not deal with insurance.   The reason that most offices do bill insurance for their patients is that it would be difficult to build a practice without accepting insurance.  One scenario that would succeed without accepting insurance would be if a dentist was so dedicated that they invested their time and money in elite classes and have reached a peak of knowledge and ability rarely seen in most dental offices.   Then, it would make sense to charge higher fees to compensate for all of the time and expense needed to achieve this.   Then, the dentist would utilize a lab technician who would put in a lot of time customizing each crown.   The lab bill would be exorbitant.   No dental insurance would recognize and reimburse this dentist at the rate of fees that this dentist would need to use.