Patient Education

Dental Insurance

Dental insurance is a wonderful benefit and a great help for many people in paying for their dentistry. Some plans help a lot, some help only a little; it depends on the arrangement agreed to between your employer and the insurance company. Dental insurance is different from other types of insurance in several ways. Most types of insurance have a sizable deductible that eliminates coverage for small claims. These insurances are designed to help cover large, unexpected expenses. Dental insurance, on the other hand, has a small deductible, covers the smaller procedures to a great extent, but covers the larger procedures to a lesser extent. For example, routine dental cleanings might be covered at 100%, fillings at 80%, and crowns or bridges at 50%. There is also a yearly maximum of typically between $1000-2000 (which hasn't changed since the '60s).

In order for the employer to save premium expense, insurance companies offer certain exclusions. A policy might be written with no benefits for bridges, which are used to replace missing teeth, or no benefit for periodontal (gum) treatment. These exclusions have nothing to do with the dental needs of the patient. It doesn't matter how badly the patient may need the treatment; if it's not in the contract, it's not covered. It's tempting for patients to say they only want treatment that's covered by their insurance. However, it's important to understand that the insurance plan was not written with any patient's best interest in mind. Limiting treatment to what the insurance covers may be hazardous to you health.

Changes In Health Insurance

Everyone is aware of the changes going on in health insurance these days. Insurance companies are under pressure to lower premiums. They in turn pressure the providers to accept reduced fees. The providers are then under pressure to alter the way they provide care in order to balance the fee reductions with the economic realities of staying in business. Some of the consequences in medical care delivery are staff reductions (specifically hospital nurses and support staff), hospitals buying physicians private practices, referrals to specialists are monitored, and everyone (doctors, hospitals, and patients) are answerable to the insurance companies.

These trends in medicine have also impacted dentistry. Dental insurance has always been inexpensive in comparison to medical insurance. There has always been an annual maximum benefit (which hasn't changed in 20 years), and usually involves a deductible and a patient co-payment. Never the less, insurance companies are applying the same pressures to dental practices. In an effort to reduce premiums, insurance companies are approaching dentists with a deal. If the practice agrees to a substantial discount in fees, those insured by the plan will be allowed to go to that practice for treatment. Perhaps "allowed" is misleading. Of course you can go to whatever office you choose, but there will be no insurance benefit paid if the office is not on the list.

There is pressure on the practice to join. No dentist wants to lose patients, particularly people we have known and cared for over many years. Joining such a plan means the practice must decide how to compensate for the fee reduction. Do you charge everyone else more, do you lay off staff, use cheaper supplies or labs, squeeze more patients into each day? These are not easy decisions, and none of these changes improves quality of care.

What is currently happening, and what you will see more of as time passes, is that dental practices will define themselves in one of two ways, based either on quality or on price. To try and find a middle ground is like standing with one foot in the boat and the other foot on the dock.

Our practice is and always will be dedicated to quality care for all our patients. We have an excellent staff, we demand excellence from the labs we use, and we do not cut corners on techniques or materials. We see this as part of our commitment to you as our patient. We will always strive to stay current through continuing education, to allow a reasonable amount of time for every patient, and to stand behind the treatment we provide.

If your insurance is changing and your new plan restricts you to offices on a list, your recourse is to communicate with your employer that you want a plan that allows you to take your benefit, whatever it may be, and seek treatment at the office of your choice.

In order to practice with these ideals, we are very selective in the insurance plans we participate. We hope you'll understand.

Coordination of Benefits

This feature is for those patients who are covered by two insurance plans. The term coordination of benefits refers to the way the insurance companies determine their benefit. This used to be pretty simple. The primary plan pays based on its plan provisions, then the secondary plan pays based on its provisions. The only limit was that the total benefits of both plans not exceed the fee actually charged. Most times, patients with dual coverage could expect minimal, if any, out of pocket expense. Things aren't so simple today.

Some insurance companies, in an effort to manage costs (meaning pay less in benefits to you), have been implementing different policies called non-duplication, carve-out, maintenance of benefits, limited coordination, non-dual, and integration of benefits, to name a few. The effect of these clauses is to reduce or eliminate payment as the secondary coverage.

As an example, let's take a crown with a fee of $700, and two plans. The primary pays $340 towards the fee. The secondary plan was predetermined to pay 50%. Because of a 'carve-out' or 'non-duplication' clause, carves out the $350 benefit from the primary and pays only the remaining $10. That leaves the patient owing $350 even with two insurance plans. This is not always obvious, even with written pre-determination by the plan. There is always fine print on the form stating the benefit may be affected by coordination of benefits.

Another, and perhaps worse scenario is 'integration of benefits'. This means that the sum of the total benefits paid by either carrier may satisfy the annual maximum of the secondary carrier. For example, a patient has a bridge made with a fee of $3000. The primary plan pays $1500. The secondary plan has an annual maximum of $1500. The secondary plan then states its maximum is satisfied for the entire plan year even though it's the primary plan which paid the $1500.

These examples illustrate the importance of understanding the specifics of your dental insurance. We agree these plan provisions don't seem fair. Your premiums aren't reduced if you have dual coverage. Our only suggestion is to make you feelings known to those in your company who have input into the nature of the insurance plan that is selected. Decisions are often made by considering what is included in coverage and not giving sufficient consideration to the exclusions.

We will do everything we can in assuring you receive the full benefits of your insurance plan, but we have no control over what those benefits are. If you have any questions regarding the plan provisions pertaining to coordination of benefits or any other plan provisions, you should direct them to your employer. If you have a description of your dental insurance plan, we will be happy to review it with you. As always, we strive to be accurate with our estimates. Thank you for your understanding. 

Insurance In Our Office

Our professional treatment is rendered to you based upon your needs. The amount of the benefits to be derived under your insurance policy is a contractual agreement between your employer and the insurance company. In other words, the benefits under your insurance plan are limited by the specifics of the contract between the insurance company and your employer. We have information about most plans, and can give you an estimate of your plan's benefits. If you have any questions regarding reasons behind limitations and exclusions, you should refer these to your employer.

Some plans offer or require a pre-determination of benefits prior to beginning a course of treatment. We will submit the appropriate forms to your insurance company. The insurance company will return the forms explaining the amount of coverage for your treatment. There is usually a three to five week turn around time for these forms.

Dental insurance typically covers 50% to 80% of the cost of dental treatment. There is usually a deductible and a yearly maximum that also apply. Some policies state they cover a percentage of the "usual and customary fee" for a specific geographic area.

 However, they are the ones who set these fees and determine the areas to which they relate, and they may not always be the same as the fees charged by this office. We will provide all the assistance we can in seeing that you receive the maximum benefits your insurance plan allows, but we have no control over what those benefits are. We will do our best to see that you receive your full benefits within the structure of your particular plan.