You Think You Have Dental Insurance?

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Would you be surprised to learn that your dental “insurance” is not really insurance. According to Wikipedia, insurance is “the equitable transfer of the risk of a loss from one entity to another in exchange for payment.” Everyone is accustomed to insurance as applied to health care or property damage, because insurance companies assume the burden of reimbursement for a high percentage of the actual costs. Everyone consequently believes that all insurance plans function this way.

Good dentistry saves time and money (and teeth!)

While most medical and property insurance fits this belief, dental “insurance” does not. In reality, dental “insurance” is a deception. It is not insurance at all–it is payment assistance. Dental plans are designed to pay a very small portion of actual costs and they are based on a system of rules that have nothing to do with the actual costs of dental procedures. Dental “insurance” companies have fees that they pay for various dental procedures. They call these fees “usual and customary”–even though they are neither usual nor customary. These fees may have been usual and customary 50 years ago, but the prices of everything have risen dramatically, and so have the actual costs for dentists providing the procedures. But the “usual and customary fees” are still the same. The patient looks at these fees and concludes they are being overcharged by dental practitioners–especially when they see “in-network” dentists accepting these fees.

So how do “in-network” dentists do it? They make up the fee differential with volume–that is, they see double or triple the number of patients in the same time period as the fee-for-service dentist. Quality dental care cannot be provided this way–quality care is painstaking and demands precision attention to detail. So the “in-network” dentists are not actually providing the same service or level of care as the fee-for-service dentist. Some “in-network” dentists cut costs further with cheaper laboratories (perhaps overseas) and inferior materials.

What you need to know

Patients who only consider the price tag in choosing their dentist do not realize that they are actually comparing apples with oranges when a better approach to consider the impact of long-term outcomes on the overall cost. Many dentists are satisfied with restorations that only last 5 years because that is when insurance benefits will apply to a new one. By looking at price only, it is common for patients to erroneously conclude that they cannot afford good the best dental care.

Most older patients who have lost their teeth wish that they had taken better care of their teeth when they were younger. One of the few pleasures elderly patients can actually enjoy is eating, and eating properly is critical for their overall health. Many of these patients require far more expensive treatments to restore proper function and oral health. In Dentistry, prevention counts, since the best care always turns out to be the least expensive in the long run.

In short, patients should recognize what a racket dental “insurance” really is. These companies regularly employ tactics to deny and delay payment of benefits. They have stringent rules as to how much they will pay annually and what procedures they will reimburse. Typically there is an insurance company dentist who makes this determination from an X-Ray. Denial of claims is a common occurrence and reasons given can give the impression to patients that unnecessary procedures are being prescribed. Regularly we provide x-ray copies to insurance companies and then have to write letters explaining why procedures are necessary and why a diagnosis cannot be made solely on the basis of an X-Ray. The insurance staff dentist never sees the patient and he or she is only trained to look at dental care in a piecemeal way, rather than from the standpoint of overall oral health.

Recently a patient needed a partial denture to replace all of the lower back teeth so that he could eat properly. The dental “insurance” company refused to pay for this partial denture because “he never had one before”. The company policy is to pay for a “replacement” partial denture. It took months before this issue was resolved.

Yes, we go to great lengths to help patients make the most of their dental “insurance” benefit. If these benefit plans come with employment, they usually provide some discount for out-of-network quality dental care. However, patients need to make smart decisions and that starts by understanding that dental benefit plans really do not qualify as “insurance.” and patients should understand that they are being deceived. It is sad that there is no legal definition of “insurance” that is based on a reasonable level of reimbursement.

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