Dental Insurance Explained
Our opinion on dental insurance: “Is it really a benefit?”
Yes and no, but it is often not as beneficial as patients are led to believe. Dental insurance is not like medical insurance. Medical insurance provides continuous financial benefits, while dental insurance provides a fixed annual limit per year (which is reduced by your total monthly payments). There are additional factors that may or may not be considered a true benefit with dental insurance. It is true that your in-network dental provider will provide care at a discount according to a fee schedule that the insurance company decides, but this can also negatively impact the quality of your care by limiting treatment options. Lastly, an issue with dental insurance is regarding limitations on what is a covered benefit under each plan. Let’s discuss each of these factors below:
Each plan will have slightly different ways in which they pay their portion of your care per year, but, generally speaking, the plan you choose will have a fixed dollar limit per 12-month cycle (please note they are not always January to December) and each plan will cover treatments at different percentages, if at all. If a plan has orthodontic coverage, there will usually be a separate dollar limit for orthodontic care, which is most often given once for the life of the insurance plan. After any limit is reached, patients can be considered, for all intents and purposes, uninsured until the new cycle refreshes and renews.
In our opinion, dental insurance limits are too low to be very useful for many dental treatment plans. No matter how hard we on the provider side try to keep your costs low, we can only get down so far before we begin to compromise your care. In our office, we always try to find the most affordable path forward without compromising your care. However, there is only so much reduction that an office or provider can make. With such low annual insurance limits, patients are most often paying full price for the remainder of their care above and beyond insurance plans’ low ceilings.
At Dental House, we provide a discount plan that many of our patient family choose over dental insurance. Often prices will be comparable without the unpredictability of dealing with insurance administrators denying care or saying they will not pay for the version of care that patients want (see “Covered benefits” below).
Due to insurance companies’ low annual limits, their solution to the problem of burning through annual limits too quickly is to simply reduce the fees that dentists may charge, as well as downgrading the care that you will receive (see “Covered benefits” below). Low fees superficially seem attractive but there is a cost that the patient may ultimately pay down the road. Because the fees that insurance companies allow are not decided by your doctors, your in-network provider may be forced to make the very difficult decision of providing your ideal care at a financial loss or selecting a treatment that allows the office to - literally - survive. In this era of rising costs (dental offices are not immune to inflation), like every other small business, we are trying to find a way through these difficult times. We want to provide our patients with ideal care, patients want to receive ideal care, but insurance companies without a doubt often stand in the way.
Covered Benefits (Downgrades)
Patients and dental offices constantly struggle with finding a path toward good oral health through a maze of hurdles and restrictions on what treatments insurance plans will cover. For example, some insurance plans will not cover any treatment related to a tooth that was already missing at the time of signing up for coverage. Some insurance companies will claim certain services are technically covered under your plan but when it comes time to provide such treatments, the insurance company may state that it will not cover said treatment because they do not deem it necessary. We cannot expect to find a doctor’s name signed at the bottom of these statements, as they are very regularly at odds with your doctor’s clinical and professional opinion. Our office personally knows doctors in town who are so frustrated with insurance rejections claiming their patients are not bleeding enough for the gum therapy they need, that these doctors have joked that they would like to ship a box full of the bloody gauze that remained following their examinations. In some cases, insurance companies may say they cover, for example, fillings, but will not cover white (aka composite) fillings. Instead, they will only pay for silver fillings (aka amalgam – which many of our patients refer to as the “mercury-containing fillings”). Composite fillings are more expensive due to the cost of materials and increased doctor’s time, yet many patients prefer them as they consider them healthier to have in the body and more attractive. Yet, some insurance plans try to dictate silver fillings or the treatment will not be covered.
What is your true insurance benefit per year?
The treatment plan a patients needs to restore oral health may be greater than an insurance plan’s annual limit – even with insurance companies’ reduced fees. However, let’s assume you will not need to do more than what your plan allows (commonly $1,500 per year). Insurance may cost from $240 to $600 per year ($20 to $50 per month). That means you will need to subtract that paid amount from your insurance benefit to calculate your true out-of-pocket benefit. In addition, you will save money by being charged the discounted fee that your insurance company dictates, but possibly compromise your care if the office cannot afford to perform it at the insurance forced rate. Each patient must decide what makes sense for him, her, or them.
Do not let insurance administrators dictate your care.
Simply put, insurance companies determine your care by its cost and whether they deem treatments, in their remote opinion, “necessary.” Your dental provider determines your care by what is ideal to reach and maintain proper health and function. Our office takes the position that no human being should allow his, her, or their healthcare to be dictated by business admins.
Our recommendation from here?
You may have reached this page after being informed that Dental House is exiting your insurance plan. Our recommendation is that you stay. As long as you have out-of-network benefits, which most plans do, it is much harder to find a skilled provider that you like than feel satisfied with saving some money that is relatively less than the loss of compromising your care. Out-of-network benefits still provide benefits to you, but there are some compromises:
- You will pay some more out-of-pocket.
- The administrative burden will fall on you rather than our front office team.
Some insurance companies make it so hard for our front office team members to work with them, it has become an unsustainable situation for the team size we currently have. So, as desperately as we have tried to avoid going out of network, for some insurance companies, we are forced to.
If you choose to continue seeing us as an out-of-network provider, almost nothing will change. You will still call to make set your visits, and you will always be just as important to us as you always have been. We will continue providing you with the elite-level, world-class comprehensive care that Dr. Park is known for. However, visits will be paid in full prior to your visit (instead of your estimated portion), and we will provide you with a stamped, addressed claim form to mail, with the insurance company mailing you their reimbursement check (like a refund). Previously, they would mail the check to us, and that, combined with your estimated portion, would pay our office in full for your treatment.
We are sorry it has come to this for some of our patient family, but we truly hope you understand that we, too, are trying to find a way to survive in this newly difficult and inflationary world.