Dental Insurance: Navigating Around the Alphabet Soup

Dental Insurance:

Interpreting and maneuvering around the alphabet soup of dental insurance can be a difficult issue for most people. Common acronyms for managed care plans are PPO, DMO and HMO. With all insurance plans, your dental benefits are negotiated between you or your employer, and your insurance company. Many insurance companies have a yearly maximum of a $1000 - $1500. Unfortunately, this maximum has not changed since the early 1970’s when dental insurance first became popular even though the cost of providing quality dental care has nearly tripled since then. Yearly maximums will not accrue if it is not used up by the end of the year. Dental insurance can help people pay for routine dental visits, but it has many limitations.

What are the differences?

With PPO or Preferred Provider Organization plans, companies negotiate fees with dentists in exchange for the dentist being put on a list of "preferred" providers. Employers give the list to their employees to match them up with dentists who participate with the dental plan. Although these may vary, most PPO plans cover preventive care, cleanings, check-ups, protective dental sealants, x-rays, and fluoride treatment at 80-100%. Basic care, including root canal therapy, extractions, and fillings are usually covered at 80%. Major care such as crowns (caps), permanent bridgework, and full and partial dentures as well as periodontal (gum) care are often covered at 50%. Coverage of fees is based upon what your insurance company decides as to be “usual and customary” for that specific procedure, which may be far below your dentist’s established fees.

In recent years, HMO’s or Health Maintenance Organization plans have received much negative publicity in the medicine. While some HMO insurance plans may be adequate for medicine, they are more difficult to justify in dentistry. The main reason is that the overhead cost in operating a quality dental practice is higher than the average medical practice, and the financial compensation from most HMO’s is very low. 65 - 70 cents of every dollar received at a dental office is relegated to office overhead.

The reduced fees allowed by dental HMO’s has participating dentists, who want to provide you quality dental care, doing many dental treatments at a financial loss. A recent study by the American Dental Association found that the average dental HMO does not even adequately reimburse inexpensive preventive dental care. Consequently, in order to make up for the financial loss, a dental practice with a majority of patients having HMO insurance is often forced to see patients quickly in order to make up the loss through volume.

DMO’s or Dental Maintenance Organizations which, on the surface, appears to create cost savings measures, creates additional costs which are not often apparent. Each participating DMO provider gets paid anywhere between $10-$30 per month for every employee that declares them as their “preferred dentist.” Providers get paid every month regardless of whether you seek treatment or not.

Accepting Insurance Versus Insurance Provider

If a dentist participates and is a provider for a specific insurance, then they have agreed with the insurance company to accept the fees and amount of coverage established by the insurance company and often times your employer. Typically, a dentist in a Fee For Service office will accept your dental insurance. That is to say, they have their own established fees, and will submit an insurance claim on your behalf. Often you will be required to pay out of pocket at the time of service, an insurance claim is submitted, and the insurance company will reimburse to you a percentage of what they regard as the “usual and customary” cost for that procedure. In other words, the balance of the cost of a procedure becomes your responsibility.

In Conclusion, Is it worth it?

Undoubtedly, dental insurance can help people pay for dental treatment and in many cases should be regarded as an adjunct to help offset dental costs, but it has its limitations. Most insurance plans have a deductible of $50 to $100, pay only a specified percentage for each type of treatment, and have a yearly maximum amount of funds available for dental care. Every dentist wants to provide you the best quality dental care possible that is in your best interest and not provide alternative treatments based on what your insurance plan may say is best for you. Many will submit your dental insurance claim on your behalf. However, often when a dentist calls your insurance to verify benefits, it is not a guarantee of payment by the insurance company and may vary according to your individual plan when the actual claim is submitted. Please also keep in mind that it is not uncommon for insurance companies to claim that a procedure is covered at time of pre-determination, to later deny that claim when submitted. If you have insurance, unequivocally, take advantage of it and use it up yearly, but understand that like anything out there, you get what you pay for.

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