Category: Insurance

Help!! Please Help Me Understand My Insurance! Part II

piggy-bank-2-1241226-1279x1304         With over 25 years as a dental provider, my staff and I have just about seen it all when it comes to dental insurance. We have seen the industry transform itself from a highly regarded employee benefit that your company offers, to plans that many question why they even bother to pay for them. In this second part, I will go into detail and explain what the dental insurance companies are now offering- the good, the bad, and the ugly state of dental insurance.

First, lets just say this up front, dental insurance is not insurance. It was never designed to be insurance, but instead really acts more like a general benefit that you may be given or sold by your employer. It does not “kick in” in catastrophic emergency like medical insurance does.  The benefit plan that you may have is negotiated by your employer to cover as much as they can get, while your insurance company is on the other side trying to sell your company as little as they can, for as much as they can get. That’s the simple truth. And the dentist has nothing to do with either side; however, we are caught in the middle trying to estimate what your benefits are and even if you are covered.

In the current market, the more typical insurance plan we are seeing now is what the industry calls a Preferred Provider Organization or PPO. This is radically different from the plans of past days. The insurance companies have far greater control over the patient’s benefits and the dentist’s fees in these plans. The insurance industry has basically shifted their costs of providing the plan to the patient and the dentist. The PPO plans cost patients more to buy. Premiums have consistently increased over the years while the yearly maximum has been reduced. Twenty years ago a typical plan would pay out a maximum of $2000-$2500 per person per year. Today, your typical PPO plan has a yearly maximum more like $1200-$1500 per person per year. This reduction of benefits has occurred while the cost of the plan, per year, has gone up from $10-$15 per month to $40-$60 per month. The patient is paying much more for far less. Also, if a dentist agrees to become a network provider for these plans, he can only charge the fee set by that individual plan. Since the PPO plans have acquired about 80% of the market, there is huge pressure on dentists to sign up with all these PPO plans. Especially the younger less established dentists who are trying to grow their new business. The insurance companies almost have total control over the benefit package for patients, the type of care they receive, as well as the fee a private dental practitioner may charge. So for the dentist, especially the new graduates, it is extremely difficult to provide high quality care with individualized attention to each patient, because the PPO plans only pay about 60% of the typical fee they normally charge. Most anyone could understand the difficulty if you walked into work one day and your boss said you were only getting paid 60% of what you usually made.

What I would suggest before you agree to buy anything, is to discuss the particulars of the plan with your dentist. We are happy to evaluate this information with you and we are only here to help you make the best decision. We are very experienced at looking at different plans and reviewing the limitations, waiting periods, deductibles, and exclusions that may make the difference between a great option or something that is not worth purchasing. Depending on your dental health or any proposed treatment, your insurance coverage needs may be different from person to person, so what is good for your neighbor might not be your best option for you.

There are also some common misconceptions about PPO’s. If you have a PPO plan, your insurance company will try to persuade you to only see an “ in-network” dentist. Regardless of your particular plan, you may choose to see any dentist and your insurance will pay a benefit. That is the one of the main advantages of a PPO. You get to pick your provider. The older managed-care plans (which are being phased out) did not give you a choice.  Your co-pay may be a little higher if you choose to see a dentist who is not “in-network”,  but depending on the procedure, it may not be that big of a difference– and if you prefer a certain dentist it may be worth it.

Another common situation that occurs with these plans is your insurance company will routinely deny benefits on a procedure or tell you that the procedure is unwarranted. If your dentist does not appeal it, you may never know that it should be a covered procedure. For all our patients and every claim that is filed, our office will specifically know if it should be covered based on your benefit schedule. And we track every single claim with a follow-up if it is not paid within 30 days. This behavior by insurance companies has been around for decades so it is vital that you have a good rapport with your dentist and his or her staff. It is extremely hard for patients to get information from their insurance company, so good communication with your dentist’s office staff is essential.  See #4 in this article posted recently about which insurance is worth your money and which just… isn’t.

In conclusion, my staff and I are here to help navigate with you through these confusing shifts in insurance. We deal with these companies on an hourly basis and are very familiar with the tactics they use to confuse both the patient and dental office. We are more than happy to sit down and help you decide which plan to choose, if any plan at all.


M. Scott Smith, DMD

Ok, Will Someone Just Tell Me What My Insurance Will Pay???

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Dental insurance can be incredibly confusing for patients to understand. Our office has been working with many types of insurance carriers for over 25 years and we have watched the industry undergo changes over these years.  More recently, we have seen some very dramatic changes that have caused many patients to question why they are even paying for it in the first place. Let’s first review some of the basics, and then we can discuss in detail some of the things that frustrate patients.

When you become active on a plan you will be given a card or a group number. You will need this information to enable providers (dentist) to relay information to you regarding your benefits. However, you must realize that even though you have a card, a group number and have been paying premiums,  many plans will invoke a waiting period on you. This sometimes means that before you can receive benefits for some types of services, you have to pay premiums for up to a year before your benefits kick in. These “types” of procedures are usually the ones that are more costly and/or immediately necessary, for example: root canals, crowns, or periodontal therapy.

…for some types of services, you have to pay premiums for up to a year before your benefits kick in. These “types” of procedures are usually the ones that are more costly and/or immediately necessary…

All dental procedures are classified according to one of about 10 categories. Your insurance pays benefits on these categories based on a percentage. Sometimes the percentage is 100% and sometimes 50%. For example, if your filling costs $300, your insurance may pay 50% of the fee they determine to be the maximum allowable. So if the insurance company’s max allowable fee is $200, they will pay 50% or $100 and you pay the rest ($200) as a co-payment. This is an example of traditional insurance. A common misunderstanding is, “if my insurance is supposed to pay 100%, why do I have to still pay some on a routine cleaning”? The reason is that the insurance company’s max allowable fee may be $85 for a cleaning, but your dentist’s fee may be $97. So the patient still ends up paying $12 on the procedure. Insurance companies will not disclose their maximum allowable fees. They keep this information proprietary and will not disclose it to the dentists. In this type of plan, the dentist has no connection or binding agreement to the insurance carrier. There can be yearly maximum limits, waiting periods on certain benefits, missing tooth clauses, yearly deductibles and co-payments.

Gone are the good old days of insurance benefits. Today, the consumer faces a much more complex array of factors: huge reductions in benefits, escalating plan costs and the necessity of having someone with inside knowledge to help you determine if your insurance company is actually giving you the correct level of benefits. All of these factors are used to decide if what you are buying is actually worthwhile.

Is the insurance you are paying for actually worthwhile?

Stay tuned for part two of “how insurance works”, as our next entry will discuss some of the new plans and how the industry is dramatically changing for our patients.


M. Scott Smith, DMD