A dentist goes to dental school and is taught all the procedures and techniques one needs to master to provide the best possible outcome for their patient. This is what becomes the basis for the standard of care.
Enter the dental “insurance” company. These companies do not practice dentistry. They attempt to practice financial wizardry. They truly care nothing for your teeth, how they look nor how you feel. They use statistics and algorithms to determine what procedures they will participate in paying for and create rules for that care that have absolutely nothing to do with true standard of care and what is best for the care of you and your teeth.
The “insurance” company, in most cases, limits the annual benefit between $1500 and $2500. This is the total amount they put forward on a yearly basis on the spend contribution for your teeth. The only thing they will pay for fully would be your cleanings twice a year and a set of routine x-rays. They usually will only pay once every 3 years for a full-mouth (FMX) or panoramic x-ray.
Your insurance premiums can cost you from $228.32 a year for single coverage to $908.40 for coverage for yourself and your spouse. This is with a deductible of $75 to $225. A maximum benefit of $1500 towards what is covered. In the meantime, coverage runs from 50% of the usual and customary fee for orthodontia, 50% for bridges and dentures, 80% for fillings and 100% coverage for cleanings and oral exams. This means you have to pay the other part that they don’t pay.
The dental “insurance” company makes their rules for what comes out better financially for their company. They will deny payments for what would be covered procedures by modifying the criteria for that coverage, particularly knowing that appeals are time sensitive, time wasting, and still in their hands for decision making. It is like gambling at the casino where the odds are always in the favor of the house. That third party injection into the relationship between you, the patient, and your dentist is like the weather which can have a huge impact on your experience. Add the silent partner making the threesome into a foursome – the employer and their requirements for the plan they’ve made for coverage of their employees and things can get very fuzzy. This then truly becomes a who’s on first, what’s on second and I don’t know on third routine, but, at this point, it’s not so comedic.
The result of this is that the insurance company dictates your care because you’ve been dragged down the path of, he who pays knows best, but the only thing the payor knows is what is best for their company. No one wants to pay more than they have to for a service, but the service actually costs more because of the requirements necessary to comply with the third-party payor.
Dental “Insurance,” in many cases, also have waiting periods. They don’t want to begin covering something like root canals or other involved procedures until enough premium has been paid to make it worth their coverage. In some cases, it may be a year before the coverage will finally be a part of your plan. Your premium is not less during the wait period.
Dental “Insurance” does not want any liability. Their feeling is the dentist is going to do what is in the best interest of their patient and ensure the standard of care is met and exceeded but it is not something the company will pay for or cover. Their coverage is not the practice of dentistry, just their definition of what a procedure is and its criteria for coverage. It has nothing to do with the standard of care. They are nothing but the payer, not the practitioner. They “dictate” after the fact how the procedure failed to meet their criteria for payment, not as to its accomplishment regarding standard of care.
Suffice it to say, Dental “Insurance” does not provide you with the protection you are led to believe. It is a well thought out and executed plan to take more of your money and lead you to believe you are “covered.” There have been so many advances in dental medicine, that are now actually years old such as implants. Implants can do more for your oral hygiene than any other procedure. Most of the payors do not cover implants, again solidifying the fact that these companies do not actually care about your teeth or your health. Dental insurance should be considered a scam.
You have a relationship with your dentist, you do not have one with your “dental insurance provider.” Your dentist is going to provide the best care, with your interest in mind. Your “dental insurance” provider may contribute towards payment or reimbursement if they decide it’s in their best interest.
Nothing will change unless you decide it should change. It’s a different mindset. When there is an issue with payment you call your insurance company and they say talk to your dental office because it’s the way they coded the procedure. You call your dental office and they’ll say the insurance company did not pay for the procedure, or they denied the procedure because enough of your tooth was not compromised to meet “their requirements” for payment. When a third party is involved, there will always be finger pointing, particularly when payment is the issue and one party has nothing to do with what happened, except they control the checkbook. The transaction was truly between you and your dental provider.
The other aspect of this three-way relationship, the dental “insurance” company wishes to keep you, the subscriber, happy and therefore has a customer service department dedicated to it members. They care nothing for the dental providers so they have a “provider” line which the dental provider waits forever to have answered to be able to check your eligibility and benefits to properly treat and bill. This information is necessary for your “insurance” to work for you. They will not speak to the dental provider unless they can give the required responses to their questions because of HIPAA, things like your social security number, your name the way it’s spelled with them on your policy, your ID number, etc. This information is necessary from you for us to be able to act on your behalf. It is imperative this is given to the dental office when booking your appointment because getting your individual benefits takes time.
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