Insurance DeniedDental Insurance

Dental Insurance - Understand your Policy

Dental Insurance – The Devil is in the DetailsThe devil is in the details

So, you choose a low-cost dental plan that claims to offer great benefits. You may be in for an unpleasant surprise when it comes time for you to actually use this insurance. Here are some questions you need to ask your insurance company:

  1. Can I go to any dentist I want? Many dental plans are network based.  This means the insurance company has contracts with some local dentists to accept reduced fees in exchange for pushing you to go “in-network”. If the plan is a DMO, HMO, or capitation, you must go to “in-network” in order to be covered by your insurance. Indemnity and PPO plans allow their patients to go “out-of-network”. In general, lower cost plans are the most restrictive.
  1. Are there any wait periods?  Some insurance plans will not cover dental treatment for a specified amount of time after enrollment. Typically, plans with wait periods require you to be insured for at least 1 year before they will pay for any treatment other then dental cleanings.
  1. Are there any pre-existing condition clauses? It is not uncommon for dental plans to refuse to cover treatment involving pre-existing conditions, such as missing teeth. For example, if you do have a missing tooth and want to replace it with a bridge or implant you may be out of luck.
  1. Exactly what services are covered? It is not uncommon for insurance plans to deny or downgrade dental services. For instance, tooth colored fillings (aka composites) may be downgraded to silver/mercury fillings (aka amalgams) which cost much less, are ugly, and many people believe are linked to health problems. Also, services such as implants, fluoride, sealants, and build-ups may not be covered at all.
  1. What are the “allowed amounts” (aka Reasonable and Customary or R&C) for covered services? Most dental plans claim to cover 100% of preventative services (such as x-rays, cleanings, fluoride, etc). This can be particularly deceptive because in reality your plan will only pay up to 100% of their R&C. For instance, most Houston area dentists charge about $100.00 for a prophylaxis (cleaning). Your insurance, which claims they will cover 100% of the cost, pays only $47.00 because that is their R&C for a prophylaxis. There are no laws or industry standards on how insurance companies determine their R&Cs. Insurance companies can set them at whatever they want. R&Cs can vary widely between different insurance plans.

On top of that, it can be very difficult to find out a dental insurance R&Cs. Insurance companies will not willingly reveal their R&Cs to you or your dental provider. In fact, this is most often the cause for discrepancies when estimating dental insurance benefits. At our office we use data purchased from 3rd parties and we track historical coverage in order to try to more accurately calculate your benefits.

  1. What is the annual maximum? After all is said and done, your insurance will only pay a maximum amount per year for your dental treatment. This can range from $500.00 to $10,000.00. Typical dental plans have an annual maximum of $2,000.00.

There are good dental plans and there are bad dental plans. Ultimately, the quality of your dental plan is directly proportional to the premium the insurance companyBad Insurance charges you (and/or your employer) for your plan. Unfortunately, dental insurance companies often market and promote bad dental plans to make them sound like a good plan.

Bad dental plans will restrict your choice of dentists and will restrict your choice of treatments. These plans routinely Deny, Downgrade, Delay (aka the 3Ds of insurance) the amount they will cover for a particular treatment. If your employer offers you a choice of dental plans, do not sign up for the cheapest one without understanding the implications!

Have you ever wondered why the cheaper the dental plan the more restrictive they are? It’s because few dentists are willing to accept the low payments these cheap insurance plans pay. Well established dentists, with happy and loyal patients, generally do not need, and will not accept, the low quality treatment and low payments imposed by cheap dental insurance plans.

Best Insurance**** Regardless of whether you have dental insurance or not, the best way to avoid the dentist is to practice good oral hygeine. Brush and floss your teeth everyday. Have your teeth professionally cleaned and examined at least twice a year. This is the best dental insurance available. ****

Dental Insurance Is Nothing Like Medical Insurance!

Many people think dental insurance is similar to medical insurance; when, in reality they are very different. Most people naturally think about medical insurance for covering costs of treatment for serious medical conditions or accidents.

Most dental ailments are preventable. Furthermore, the cost of diagnosis and treatment of a dental ailment is usually predictable and manageable. This is very different then medical ailments which are often unpredictable and the cost of diagnosis and treatment can be prohibitively expensive.

Because most dental ailments are preventable, most dental insurance plans are designed to encourage the patient to receive regular and routine preventive care. Just about all dental insurance plans will gladly pay to have your teeth cleaned and examined by a dentist twice a year.

The majority of dental insurance plans are designed to cover only a portion of the total Dental Insurance Formscost of a person’s necessary dental treatment. To control cost even more, most dental plans will only pay the cost of what they feel is sufficient to correct the ailment. For example, most insurance companies downgrade composite fillings, which are tooth colored, to the less costly and less desirable amalgam fillings, which are mercury based and silver colored. They do this despite the fact that most patients do not want silver fillings and many dentists refuse to place them. Denying, Downgrading, Delaying (the 3Ds of insurance) of benefits are common practice when it comes to dental insurance.

Another problem is that the maximum annual dental insurance allowance is usually around $1,500. This allowance hasn’t changed since the mid 1970s, even though dental fees have increased significantly over the last 40 years due to inflation and higher overhead costs.

This creates a dilemma for both the patient and the dentist. The dentist wants to treat the dental ailment as early as possible so it will not worsen or cause more serious problems down the road.  The patient, who may need treatment on multiple teeth, wants to limit treatment upto the maximum annual dental insurance allowance; putting off subsequent treatment until the following year when they have benefits again.

The decision to delay dental treatment may lead to more extensive, more expensive, and more invasive procedures in the future.  Additionally, you may also be risking your general health as a whole.