Passionate Artistry

Dental Insurance Hazards

health insurance benefits floridaDentists know that patients who do not have insurance wear the healthiest and most beautiful smiles. Patients on HMO plans have the least healthy mouths. Does that mean insurance is bad? Not at all! But, watch out, you could easily become a victim of insurance traps.Here is an interesting fact. The least healthy mouths that dentists see are in patients with HMO insurance plans. Slightly better are patients with PPO insurance plans. Patients with indemnity plans have the healthiest “insured” mouths, but the uninsured have the healthiest mouths of all!

You might expect that the healthiest mouths would be among the wealthy that don’t have insurance. In actuality, many people on limited incomes have the healthiest mouths. Yet many wealthy individuals have lousy teeth, poor dental habits, a history of sporadic dental visits, AND DENTAL INSURANCE. Could it be that the uninsured invest their time and dental dollars more wisely and don’t look to dental insurance as their income source for dentistry?

Patients without dental insurance are an interesting group. Most have excellent dental home care skills. They seldom miss a regular dental cleaning and exam. They rarely need much dentistry. They are not afraid of the dentist. In short, they place a high value on their health and smile. Would you like to be in this group? It is entirely possible for you to move from outside this group to inside this group.

For patients with dental insurance, it is great to have someone else share the cost. But dentists think, “Okay, here comes another patient about to be let down by what s/he thinks her insurance covers.” This article will help you avoid disappointment from your insurance.

There are three classifications of dental insurance (HMOs, PPOs, and indemnity) and one self-insurance alternative. What patients typically expect for coverage and what is actual coverage often different:

Unfortunately, most patients do not have a full understanding of what they get when they sign up for a particular plan. The following descriptions may help you decide.

HMOs (Health Maintenance Organizations)

The Coverage – The insurance company contracts with dental offices to provide services at greatly reduced fees from UCR (average) fees in your area. Your exams and cleanings are included, and often there is no deductible. The only payment made from the insurance company to the dental office is a monthly capitation fee (usually $7-12/mo per person covered) to provide these services whether you use the services or not. HMO plans do not have an annual maximum.

Behind the Scenes – Dental management companies, not the apparent owner dentists, control the activities of most offices that participate in these plans. These offices accept many managed care plans, not just yours. You may have heard of some of these companies going bankrupt, which tells us that most of the remaining companies have become very skilled at controlling expenses, including doctor’s salaries, staff salaries, dental supplies and laboratory costs. In addition to controlling expenses, other efficiencies are usually instituted. The most evident of these is overbooking patients which results in increased waiting time in the office, both in the reception area and during treatment. The dentists working in managed care may be managed care veterans, new graduates and foreign –trained dentists who are now licensed in the state.

The Surprises – A dental exam and cleaning including scaling, polishing and oral hygiene instruction is scheduled for 40-60 minutes in most dental offices. Dental cleanings in HMO offices are much less thorough and take anywhere from 10-30 minutes with x-rays. In California, the average high quality dental crown costs $800-1100. Yet you may have an HMO plan where you pay as little as $290 for a crown. How can this be when the average dental office has expenses equal to 60-70% of the cost of a crown? Volume dentistry and utilization of inexpensive (i.e. “cheap”) dental labs help control expenses, but the truth is that unless you are doing a bunch of crowns at once, the dental office loses money by doing a crown for $290.

Here is what you can expect to be told if you need a crown under HMO coverage. “Sir, your plan covers non-precious metal crowns. These crowns are not strong like porcelain fused-to-gold crowns or our latest super-duper crowns,” which the doctor is recommending. “The additional fee for the nicer crown is $700. Which crown would you like the doctor to do for you?” While this comes across as a bait and switch tactic, it is more appropriately described as a benefit and value recommendation. The office is entirely correct in “selling” you the better crown, because it is the one that will be the healthiest for your mouth, it will fit better, last longer, feel better and look better.

Many, many procedures are not covered by managed care plans. This is the biggest surprise for patients. For example, tooth colored fillings may be covered in the front six teeth, but not in the back teeth. You may have to pay full fee to receive tooth colored fillings, which are the preferred technique that is in use today. Even services on broken teeth may not be covered, unless the breakage was due to decay. Over and over again, patients on these plans complain because they thought their benefits were greater than they actually are. The informed consent form on the following page is an example of what some offices provide to patients regarding HMO coverage. Read this form thoroughly before committing to an HMO plan.

The Good – These plans provide at least some coverage and are an incentive for patients who have neglected themselves to start seeking dental care.

Myth – Managed care patients must receive all their dentistry from an office listed in the book of providers. While listed offices are the only offices to provide benefits specified by the insurance plan, managed care patients are free to chose any dentist and pay the going rate (or negotiate fees) on their own. In many cases the fees will be similar, but the quality will be better by selecting a fee-for-service office.

The following is a possible Informed Consent form that would apply for an HMO practice.

INFORMED CONSENT (HMO benefit plans)Patient’s name _______________________________________ Date ___________________Health Maintenance Organization benefit plan limitations (HMO)General: HMO dental benefit plans have more restrictions and limitations on covered services than what patients are used to with conventional insurance.Least Expensive Option is “Covered Benefit”: Alternative treatments are always available for any given dental condition. Seldom is the least expensive treatment the best alternative. Nonetheless, it is generally only the Least Expensive Professionally Acceptable Treatment (LEPAT) that is the “covered benefit” for HMO type benefit plans, no matter how few patients ever choose this alternative (or how few dentists would recommend it).Diagnostic Procedures are generally a “covered benefit” at 100%.Bite Corrections may be necessary before undertaking any other treatment, but they are NOT COVERED.

Crowns, Inlays, and Onlays are NOT COVERED where a tooth can be filled (no matter how unadvisable) instead, only the filling is “covered”. The difference in fees is the patient’s responsibility. Even where the crown is a “covered benefit” because a filling is impossible, the cheapest crown possible (made out of base metals with no porcelain on molars) is the “covered benefit”. The difference in fees is the patient’s responsibility.

Composite fillings are often greatly preferred to amalgam (silver/mercury) fillings, but amalgam fillings are the only “covered benefit”. The difference in fees is the patient’s responsibility.

Fixed Bridges are often the best replacement for multiple missing teeth, but in many cases only Partial Dentures are a “covered benefit”. The difference in fees is the patient’s responsibility. Even where the bridge is covered, the cheapest bridge possible (made out of base metals with no porcelain on molars) is the “covered benefit”. The difference in fees is the patient’s responsibility.

Implants are now considered a routine and preferred treatment in many cases, but they are usually NOT COVERED.

Extraction of Wisdom Teeth is often an important part of overall good health, but is only a “covered benefit” when the tooth is causing problems that cannot be solved with antibiotics and pain medications. Even when extraction of wisdom teeth (or other teeth) is a “covered benefit”, it is NOT COVERED at an oral surgeon’s office (no matter how desirable that may be) unless certain strict criteria are met (relatively rare). Even when extraction is a “covered benefit” at an oral surgeon’s office, general anesthesia is NOT COVERED.

Periodontal Maintenance: Although over 80% of adults have at least some periodontal disease, requiring prophylaxis (cleaning) an average of four times annually, only two such visits are a “covered benefit” each year. The other (two) visits are NOT COVERED and are the responsibility of the patient.

Wear and Tear, Abrasion, and Attrition cause many teeth to need restoration, but such restorations are NOT COVERED. Only restorations that replace tooth structure lost due to decay are a “covered benefit”.

Collapsed Bite and Extensive Restoration: When back teeth are missing or worn, the bite may “over close”, causing strain on joints and trauma to teeth. Restorative procedures designed to correct for this devastating roblem are NOT COVERED, nor are any other complex (full mouth) restorative procedures.

Consequences of not performing procedures that are NOT COVERED: Your teeth do not know or care whether the treatment they need is a “covered benefit” or not. Failure to timely accept recommended treatment from your dentist can lead to pain, infection, tooth loss, expense, and medical risk.

HMO insurance plans are at times very confusing to all involved. Every reasonable effort will be made to ensure that your HMO dental benefits are completely explained, although it is not possible to guarantee perfect understanding or accuracy. By signing below, you acknowledge that you have received, read, and understood the information given above regarding the limitations of your HMO dental benefit plan, and that all of your questions have been answered fully.

__________________________________________ __________________________________________

Patient’s signature / Date


PPOs (Preferred Provider Organizations)

The Coverage — With a PPO plan, the dental insurance company contracts on your behalf with dentists in its network to provide services at a reduced rate fee schedule. These rates are generally 20 percent to 30 percent below fee-for-service fees in your area. The insurance company pays a portion of your dental expenses and you pay a portion of your dental expenses. With preferred provider plans, you may go out of network for your dental care, but your benefits will be limited to approximately what they would be if you saw a dentist within the network. There is usually an annual maximum designed to limit the insurance company’s risk.

Behind the Scenes – Many good dental offices dabble in this segment of insurance, accepting just one or two plans to help keep their chairs filled, while limiting their exposure to these loss leaders. Most dental offices that see HMO plans also accept almost all PPO plans, because the reimbursement is higher from PPOs. For the dabbling offices, there may be no difference in services you receive from those received by cash or indemnity patients. However, any office that sees PPO patients will eventually have to institute better expense management protocols, some of which may affect the quality of care you receive.

The Surprises – If the office where you are seen also accepts HMO plans, you will be subjected to the same service limitations as the HMO patients. Unlike HMOs, annual maximums may influence you to receive less than the amount of care required to bring your mouth to health.

The Good – PPO plans do not control you as drastically as HMOs. You may receive benefits for many services that are not included in the benefit structure for HMOs. In comparison with indemnity plans, pre-determination of benefits is less necessary to assure your coverage for recommended treatments. You may find a dentist who is primarily a fee-for-service dentist who only accepts one or two PPOs. This is usually the best situation for those with PPO coverage, because that dentist is stating a willingness to discount fees to a limited number of patients with less need to reduce the quality of the dentistry provided.

Myth – You must see a preferred provider and preferred providers receive the highest benefit from your PPO plan.

Truth – Fee-for-service dentists may even be reimbursed at a higher rate than dentists who are members of your plan. The difference in what you pay to see a preferred provider versus a non-member may be negligible, so if you have a great dentist who is not on your plan, you might be wise to stick with that dentist.

Indemnity and Fee-for-Service

Indemnity plans pay a percentage of the dentist’s standard fee for services rendered. These plans are getting rarer, except for company executives, because most companies limit their insurance preium costs as much as possible.The insurance company may work from a table of allowances that reflects average fees in your region.

Behind the scenes –Insurance companies must control their paid benefits, therefore there are attempts on the insurance companies’ part to slow payment and/or decline benefits. This “work slowdown” is part of the insurance game. Many dentists will fight on your behalf, but others are quite tired of this game and will ask you to do all the dealing with the insurance company. This approach is understandable, because your contract is between you and the insurance company. Be sure you are comfortable with how your dental office handles these plans before commencing treatment.

The Surprises – Of all the types of dental insurance, indemnity plans are the clearest in stating your benefits. The real surprise comes when we find out how little the benefits stretch if you need any major dental work. Dental insurance was in its infancy in the early 1970’s. Most plans had a $1000 maximum. With this maximum a patient could have ten crowns in one year and still not exceed the maximum benefits. Today, many plans have adjusted the maximum to $1500, but this will barely cover the insurance portion for three crowns. Because seniors often require gum treatments and root canal therapy, it is not unusual to find benefits depleted with just one crown. Dental needs seem to come in bunches (not one tooth per year), so you should be prepared to cover the cost of your needs beyond what an indemnity plan will pay.

If you have an indemnity plan and you select a dentist who provides primarily managed care services, you should expect to receive the level of care that is given to managed care patients.

The Good — Indemnity insurance does not control the quality of work provided by the dentist. Therefore, you are freee to find a quality-oriented dental practice where you will be comfortable with the level of service provided. These practices usually respect your time more, have better trained staff, and pay for higher quality laboratory work.

Myth – Fee-for-service dentists are those dentists who are so busy they do not have to accept managed care plans.

Truth — In some cases this is true, but in many other cases the dentist is not that busy, but is very committed to providing an uncompromising quality of work.

All of the above plans do not cover “optional” dental services such as tooth whitening or veneers to straighten crooked teeth. One additional type of coverage is more likely to cover these benefits…

Direct Reimbursement

This is not insurance but a plan where an employee is reimbursed for out-of-pocket expenses, up to a certain maximum dollar amount per year. This places the patient in total control of treatment decisions, which is where most patients prefer to have the control. Some companies have what is referred to as a “cafeteria plan” where the employee may adjust overall benefits prior to the year in which the benefits are granted. If you were covered by such a plan and knew that you were going to have Lasik eye surgery one year and dental crowns the next, you could direct your benefit dollars into the appropriate category to receive maximum benefits.

The Surprises – Most companies limit their exposure during the early years of a direct reimbursement plan, so during these years your maximum benefit may not be as high as insurance plans. However, experience shows that benefits can actually be much higher after a plan has been in effect for a number of years.

The Good – Direct reimbursement allows a larger portion of dollars to go directly toward your care, since costs for administration of such a plan are minimal. Contrast these minimal costs with dental insurance administration that may run upwards of 40% of premiums received. For many companies, this means they may actually pay less than with a dental insurance plan. For patients, direct reimbursement usually provides benefits even for elective services (such as cosmetic dentistry). The wait time for reimbursement is usually much shorter than with an insurance plan.

Myth – A direct reimbursement plan will cost my company too much because of higher utilization. This has proven not to be true. Utilization is predictable and reimbursement levels can be controlled in the initial years for overall cost savings.

No Insurance at All

Many patients bemoan the fact that they do not receive dental benefits from their work. This does not have to be a negative situation. Remember the earlier discussion… those without insurance have the healthiest mouths. It seems that many insured individuals have come to rely on insurance companies to dictate their dental choices and expenditures. They forget that it is the insurance company’s business to make money, and therefore pay out the minimum benefits possible.

It is rare for dental insurance these days to provide more than $1500 annual coverage. This may barely cover the cost of one root canal and one crown. Unfortunately, dental needs usually come in bunches, and as we age, a big bunch is more likely to occur, often the year after we retire and lose insurance benefits. The insurance companies know this. There are some dentists that allow the insurance companies to dictate the dentistry also. These dentists provide crowns for the one or two worst teeth, even when health criteria dictate multiple crowns. The result after a number of years is a hodgepodge mouth with more gum destruction and rough areas to catch floss. Patients who are not looking at insurance benefits all the time are more likely to make decisions for their own good.

Whether you have dental insurance or not, unless your dentist tells you there is little or no wear in your mouth and your gums are perfect, I encourage you to plan for the rainy day. Patients who do are most likely to carry beautiful smiles into their 80’s and 90’s.

How to Pay for Dental Care

Due to the limited coverage of most insurance plans and the costs of dentistry, anyone seeking a healthy mouth without compromised dentistry may have to come up with a substantial amount of the fee out of pocket. While many people have the ability to pay their portion, many others are not prepared. It is also true that delaying dentistry can make for even higher costs, not to mention compromising health and the enjoyment of a great smile.

To deal with this, many dentists offer short term in-house financing or participate in dental financing plans with no interest or low interest. One such plan is CareCredit. Application may be made online for all dental procedures, including elective dentistry, even prior to seeing a dentist.

An alternative to assist patients without insurance is a newer non-insurance dental membership plan. These are low cost plans that provide basic services (cleanings, exams, x-rays, etc.) at no extra charge and a savings on most other dental services at a membership office.

Next Chapter: How to Select a Dentist

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