What’s the real story on dental insurance?


04-06-2016

What’s the real story on dental insurance?

Dental insurance is a nice benefit to have, especially if your employer is paying for it. But many people don’t understand how dental insurance works. Dental insurance is unlike medical insurance, because dental insurance has an annual maximum benefit that is typically limited to $1,500. So even if you need every tooth treated, insurance will only pay $1,500 of the total fee. That’s the most you can hope for in any calendar year.

Benefits are usually paid only after you pay the first $50 (deductible). Insurance plans often say that they pay for 100% of cleanings, 80% of fillings and extractions, and 50% of crowns. BUT… those percentages are based on arbitrary fees created by the insurance company, not based on what dentists actually charge in private practice. For example, we charge $500 to remove a tooth. One insurance company recently told our patient that their “allowable” fee for an extraction was $83 and, of that, she would receive $64 in coverage.

Insurance companies tell patients to get pre-authorizations before treatment. But does that help? No. Pre-authorizations do not guarantee benefits and only delay treatment that the dentist has already determined to be necessary. “Final determination” is only after your treatment, according to insurance companies. This is why we do not pre-authorize treatment.

After hearing from former insurance company insiders, we learned about some of their tricks to maximize their profits at your expense. Delaying, denying and “down-coding” (the 3 D’s) are central to their strategy. They delay payment by asking for more information and by “losing” claims. They deny payment by saying that your treatment is not covered and by saying that you are no longer eligible. And they “down-code” by covering you for a silver-mercury filling when the dentist gives you a tooth-colored filling.

Since 1999, we have been an out-of-network private practice, independent of insurance company affiliation. This allows us to prescribe the best options for your treatment, without insurance companies dictating what you can and cannot have. With information on all legitimate options, and with professional guidance from us, the treatment you choose is up to you, not an insurance company.

Dental insurance is a nice benefit that employers offer to help reduce your dental expenses, but it’s important to understand what to expect from dental insurance. Dental insurance companies want to maximize their profits by minimizing benefit payments. Your dentist wants the best dental care for you.