Dental Insurance

What if you have no insurance?

Having dental insurance is a good thing, but it is not essential to gaining access to dental care. On the other hand, medical insurance is virtually essential to gaining access to medical care. In the world of medicine, treatment for even a minor illness frequently runs into the thousands of dollars. This is NOT the case with dentistry. Dentistry differs from medicine in that dentists compete with each other on the basis of fees, while physicians do not. (Consider, for example, just what the cost of a 40-minute surgical procedure would be by a physician compared with the $80-$500 for that much time and skill in the dentist's chair. Plus, hospitals generally bill separately for anesthesia and supplies.) Most people can afford to pay for dental emergencies out-of-pocket, and an entire treatment plan can be very affordable especially if it is financed over the course of a year or two. What this means is that no one should avoid needed dental care just because he or she does not have dental insurance.

It is helpful to place the cost of dental care in perspective. Most patients, even with serious problems, can receive a reasonable treatment plan that will produce basic stability of oral health and a good smile for under $3000. This assumes a fair number of fillings, some extractions and maybe a partial denture. Payment is usually made as the work progresses, over the course of of time that it takes to complete the treatment plan. Several financial plans are available as well for financing treatment over as many as five years.

Insurance Facts

The insurance company will do exactly what is written into its contract with your employer....No more. The insurance company's primary allegiance is to its stock holders. Any advertising which implies that a big company cares about you personally is only advertising, and is based strictly on their legal obligations to the policy holder. They don't care if you are in pain, or your mother is sick. They won't pay for something just because you need it or want it.

The coverage you get is based on the policy your employer buys with the company. The employer makes the decision about the type of policy based primarily on financial considerations. Insurance companies bank on the statistic that the average employer switches insurance carriers every 5 years. Therefore, they are only interested in providing coverage for procedures that will last 5 years, not 15 or 20. If you want to know what is covered by your contract, read the fine print.

The following discussion is only a general guideline to how the basic plans work. In reality, different plans can overlap so that an HMO may have some of the characteristics of a capitation plan, or private insurance may have some restrictions like those in an HMO or PPO. It is very very important to read your policy to find out the specifics about your plan.

Capitation Plans

In a capitation plan, a dentist signs a contract and is paid a small monthly fee for each patient, or each family that has signed up with the plan. The dentist receives this small monthly fee even if the patient does not show up at the office for treatment. In return for that fee, the dentist provides exams, cleanings, x-rays and sometimes emergency visits for contracted patients who appear at his door. In addition, he agrees to a fee schedule for a set number of procedures, some of which may be paid partly by the patient and partly by the insurance company, or may be paid entirely by the patient himself. The fees are generally set very low without regard to the dentist's overhead or local market value. Capitation plans have fared very poorly in dentistry because they frequently do not cover the dentist's expenses.

Dental HMO's

Health Maintenance Organizations were designed to "manage" the delivery of health care. The HMO acts as a "gatekeeper" and "manages" the expenses by setting the fees and telling the dentist what he will, or what he will not be paid to do. The dentist signs a contract with the HMO. He receives a fee schedule set by the HMO and is paid by the HMO for some of the contracted services. The fees are generally below market value. If the procedure that the patient needs is not on the list, the patient will have to pay for it out-of-pocket. The HMO makes an issue out of telling patients that their doctors are not limited in what they can do for a patient, but the fact that the dentist will not be paid for performing a particular procedure sends a fairly strong message. Medicaid is probably the best-known example of an HMO.

The concept of "covered" procedures is not as straight forward as the HMO would like you to think. A procedure listed on a fee schedule with an amount that can be charged does not necessarily mean that that amount will be paid by the insurance company. It may be fully paid by the patient. Thus, the insurance company can state the procedure is covered on the plan, but still pay nothing toward its completion. This often leads to confusion and frustration, not only for the patient, but for the dentist as well.

Lastly, most HMO's require that the patients be treated by a contracted dentist. This also means that the provider must also refer to contracted specialists. This is not the case with every HMO, but it is true for most. If there is no local contracted specialist available, then the HMO may, or may not allow the primary dentist to refer to one that is not contracted. If the patient sees an out- of-plan specialist, the HMO is not necessarily obligated to cover any of the specialist's fees leaving the patient to pay out-of-pocket. The other downside to this arrangement is that the insurance company is interfering in the professional preferences of the primary care dentist. It then becomes possible that the general dentist may be forced to refer to a specialist in which he or she has little confidence.

PPO's.

PPO's (Preferred Provider Organizations) are like HMO's in that they have a network of dentists with whom they have a signed contract. Patients may choose a dentist on the PPO list, or choose a dentist outside the "network". Because a PPO dentist accepts a payment fee schedule, the patient's out of pocket expenses may be higher if he chooses to go to a non-PPO dentist. This is because a PPO fee schedule will generally be lower than the dentist's current fees, and an out-of-network dentist is under no obligation to accept the PPO fees. The difference may be minimal or large. CAUTION: It is important to find out if your PPO allows payment to out of network dentists. Some may not.

Private dental insurance

Private dental insurance is insurance with fewer restrictions. The dentist generally signs no contract with the insurance company. Note that not every employer purchases a standard policy, which is the one described below. Some private policies vary substantially from the standard, and you need to check your company handbook concerning exactly what your policy does cover. In general, dental industry standards traditionally pay under the following schedule:

Type I (Cleanings, x-rays, exams, preventive and diagnostic procedures)	100%
Type II (Fillings, root canals, extractions, many emergency procedures, most surgery)	80%
Type III (Crowns, bridges, dentures)	50%
IMPLANTS, veneers, bleaching, crowns done for esthetics only	0% (No coverage)

Most policies have, a yearly limit of $750 to $1500 and a deductible of $25 to $100. "Deductible' means that the patient pays that amount prior to the insurance paying anything at all. Please note that insurance plans frequently waive deductibles on Type I procedures. After insurance payment the balance due is called a co-payment and is paid by the patient. It is illegal for a dentist not to collect the co-payment.

Within the private insurance sector, there are numerous levels of coverage. There are so many different policies that it is impossible for the dentist to know what is covered and what is not. It is important to read your policy carefully. You can generally find information pertaining to your policy in your company handbook, or in the personnel office where you work. Insurance companies will NOT usually cover work done for purely esthetic reasons. This includes bonding to close spaces, veneers on front teeth, and bleaching.

Direct Reimbursement

Direct Reimbursement is where the employer directly reimburses the dentist (or the patient) for dental expenses upon receipt of a valid bill. There is an agreed upon yearly amount that the patient may draw from. In general, there are no questions asked as to what was done, or why it was done. That is between the dentist and the patient. Bill submitted, bill paid - it's as easy as that! Anyone having this type of plan does need to check to see if there are any specific requirements (such as time frames for submitting bills) and be sure to follow them.

Direct reimbursement is fairly new in many areas. It is generally an EXCELLENT type of reimbursement and is a win/win situation for the employer, patient and the dental office. The employer is saving money by bypassing the costly "insurance" purchase and all the paperwork involved. The dental office does not have to deal with time-consuming insurance paperwork, fighting the insurance company for benefits that weren't paid but should have been, trying to justify payment for necessary treatment that an insurance consultant won't approve for payment, or waiting weeks to get approval for a procedure that the patient needs but cannot afford to undertake without insurance coverage. With direct reimbursement the patient is allowed to apply benefits in whatever manner he/she chooses. This reduces waiting time for costly procedures and often allows patients more choices in treatment.

Insurance that isn't insurance

One more plan should be mentioned, because everyone runs into it sooner or later. They are referral services masquerading as insurance companies. You might see a brochure in a supermarket or at the mall. Some even advertise on TV. Generally, the patient pays a monthly fee ($6-$10), and the company refers you to a dentist that accepts their "plan". Before signing up for this plan, PLEASE call the "plan coordinator" at the company and ask them how much THEY pay toward your dental work. If the answer is "nothing", then this is NOT insurance. This is a referral service. This service will have a contract with a dentist who will accept their schedule of fees.

The largest referral service, seen on nationwide TV, has a 1- 800 phone number and is free to patients, but extracts a heavy monthly fee from participating dentists. A large majority of dentists cannot afford to pay this fee and are consequently not listed. Our office has been approached by this service, and we declined. Their advertising suggests the dentists' credentials are of prime importance to the referral service, but the primary reason why any dentist would not be listed is because of this monthly fee.

Some important questions

What is a Pre-treatment estimate?

A pre-treatment estimate or "pre-determination" is the same thing as asking a stranger to look at a picture and tell you if they think you should have a procedure done. Generally, this allows the insurance company to find an excuse to say "no" to treatment that your dentist has recommended to you, based on his/her clinical skills and judgement. Unfortunately, the pre-treatment estimate is valid ONLY on the day it is processed, and the insurance company may refuse coverage for the procedure in question anyway when it is performed. In our office, we have found that submitting for pre-treatment estimates or pre-determinations results in getting less insurance benefit coverage for our patients. Once an insurance company says "no" to treatment that has not been performed, there is no way to change its collective mind.

Is my insurance company good?

This question deserves special attention because it is asked so often. There are actually two answers to this question.

From the point of view of the dentist and the office personnel, a good insurance company pays what it states it will pay in a timely manner without insisting on unnecessary paperwork. It has a legal obligation to pay what is written in the contract, but sometimes it can be very hard to collect. As a dental office, we judge an insurance company by how well it fulfills its obligations to its policy holders, and how much trouble we have to go through to collect that payment. Unfortunately, this is not usually what the patient is actually asking.
The patient actually wants to know; "Does my insurance plan give me good coverage?" The answer to this question is that one insurance company may offer hundreds of different plans varying from 0% to 100% coverage on any given procedure. Some very good companies offer some very low benefit plans. That same company may offer much higher coverage plans as well, but the employer has decided to purchase a low benefit plan instead. As a dental office, we are not in a good position to tell you what your particular benefits are. If we give you specific answers, we may be wrong. To answer this question, check with your company personnel office and compare your plan with the guidelines provided in the standard insurance table above. Be sure to check the yearly maximum.

Why doesn't your office accept my HMO (PPO, capitation plan, contract insurance)?

The decision of whether to accept a particular plan or not is based on financial and ethical considerations. In many instances, the plan's contract does not provide high enough fees to justify the amount of time the dental office must spend training for and performing the various services at the standard of care chosen by the dentist. Sometimes, the restrictions that the contract levies on the dentist may prevent him from serving what he feels are the patient's real needs.

Larger offices with numerous associates may be better able to offset the low fee schedule by allowing that office to produce a greater volume of work. Smaller offices frequently cannot. By accepting the fee schedule of any of these plans, the dentist is implicitly stating that he agrees with the treatment objectives of the HMO.

None of this means that the insurance company is wrong in its policies. It simply means that each practitioner has legitimate reasons for rejecting the terms set fourth in the contracts offered. Some dentists simply cannot compromise their standards of care because of their own personal professional ethics.

© Copyright 2003- Dental WebSmith, Inc. and Kevin D. Huff, DDS. All rights reserved. Disclaimer: The information provided within is intended to help you better understand dental conditions and procedures. It is not meant to serve as delivery of medical or dental care. If you have specific questions or concerns, contact your health care provider.