Philosophy of Insurance Benefit

I have a difficult time explaining dental insurance to my patients. Often times Debby and I are caught between the patients’ expectations of their insurance benefits and the actual money their company pays toward a procedure. Dental insurance isn’t really insurance at all. It is actually an amount of money, provided by an employer, to help their employees pay for routine dental care. Understanding your dental benefits is not easy. There are many different plans. Your employer has selected your plan and ultimately is responsible for what is covered. Whether your plan covers a major portion of your dental bill or only a small amount, dental benefits are good for patients because they help pay for needed treatment.

It is important to note that each dental plan will specify what types of procedures are considered for benefit. Even if a procedure is dentally necessary, it may be excluded from your plan. THIS DOES NOT MEAN YOU DO NOT NEED THE PROCEDURE. It just means that your plan will not consider the procedure for payment. I believe it is a mistake to let your benefits be your sole consideration when you determine what you want to do about your dental condition. There is no doubt that the cost of dental services can be a deterrent to getting the treatment you need. Most dental offices, including ours, will provide some alternatives to help you defray the cost of services over time.

There is commonly, an annual benefit maximum on most dental plans. Many patients are paying for an annual benefit that hasn’t changed since the 1960’s. In 1968 my father bought a new Ford Mustang for about $2500. The annual dental insurance benefit at that time was $1000 per year. Because of inflation and other factors the price of a new Mustang is about $25,000, or 10 times as much. What YOU PAY to the insurance company for your benefit has kept up with inflation. But, unfortunately your annual dental benefit has remained at $1000 per year. Logically, as compared to 40 years ago, if your insurance company charges you 10 times as much for your average annual dental benefit your benefit should be closer to $10,000 per year. Our costs to provide dental services have also risen with inflation. It’s not OUR services that cost too much. I believe it is more a factor of the insurance companies not providing a reasonable dental benefit package that prevents many patients from having access to ideal care.

An acronym that is often times floated around by insurance companies is UCR or usual, customary and reasonable fee. Your employee benefits coordinator may try to tell you that since our fees are more than the UCR, we are charging too much. The UCR is always less and sometimes much less than what most dentists charge for a specific procedure in your location. A more accurate description of UCR is “negotiated payments”. The reimbursements for specific treatment procedures are negotiated between the dental INSURANCE COMPANY and your EMPLOYER. It has nothing to do with what your dentist feels is a fair fee for the procedure. A dentist, like any small business owner, bases his fees on what it costs him to provide the service, his level of expertise or training, and what other professionals in the area are charging for the same procedure. That’s how most service related businesses determine their fees.

Many insurance companies do not pay enough of a benefit to cover the cost of the dentist providing the service. A business cannot survive if enough monies are not available to pay for rent, pay for employees salaries and pay for supplies. That is why I’d be very suspicious of dentists that appear on “a list” provided by the dental insurance companies. Dentists who are on a list or more commonly called a “Network” receive lower compensation from their carriers. The only way they can remain profitable is to perform more procedures. This is the atmosphere that is created by dentists that allow these very restrictive managed care plans into their practices. This type of business atmosphere is not for me! My philosophy is to provide my patients with the best treatment available at the lowest cost I can. The cost of doing business at the level of care I want to provide is more than a managed care plan is willing to provide as a benefit to its clients. Therefore I choose to work with those insurance companies that allow their clients to make choices that are in their own best interest. In so doing I have a lot of healthy patients in my practice.

Please remember that even if a benefit plan does not cover a large portion of the cost of needed dentistry at least it covers something. Any amount covered reduces what you have to pay out of pocket. An insurance that pays the majority of treatment is ideal. But unfortunately those plans are few and far between. Currently, unless you are fortunate enough to have one of these plans, and you want to have treatment that your trusted dentist recommends, much of it will be paid by you. Most practices that want you to have ideal treatment have made arrangements with financing agencies (like Care Credit) that can help you in paying for the dentistry you need.