The Ins and Outs of Dental Insurance

When you see the words dental insurance you automatically think “oh, it’s like medical insurance” and I need to tell you that thought will get you into trouble as the only thing dental insurance really has in common with medical insurance is the following: a special set of codes are used to describe procedures for billing, you pay premiums for dental insurance just as you do with medical insurance, and in many cases dental insurance also carries deductibles.  Dental insurance has a public access – Medicaid (Medicare itself has no dental coverage except for their Medicare Advantage plans), and private in which you buy your own policy or employer-based plan.  These plans are further divided into the following types:  PPO (preferred provider organizations, DHMO (Dental Health Maintenance Organization – likened to the HMO Medical plans) and the discount or referral dental plans in which you buy into a plan and thus get into their network but you pay out of pocket the discounted fee schedule of that plan with no benefit plan from the insurance company.

Dental Insurance Payment Categories

Dental insurance is usually split into three different payment categories:

1. Diagnostic and preventative care, including x-rays and cleanings, which usually pays at 90 – 100%
2.  Basic usually restorative care, including fillings and root canals paying at 70 – 80%
3.  Major restorative care, including dentures, bridges and crowns usually paying at 50- 60%.

These percentages are of the insurance company’s fee schedule or the usual and customary fee schedule of the practice.  The dental insurance company plan also has a maximum amount that they will cover and once that maximum is met, they do not pay any further claims for the year.  It is important to pay attention to this money as you’ve paid for it with your premiums and you do not get your money back and if you have not used it all, the insurance company keeps it as it does not roll over to the new year.

Bring your dental insurance information to dental visits!

When you go to your dentist’s office it is very important you have your dental insurance information. Your card should say dental on the back of it with a DENTAL phone number that can be called to verify your insurance is active and the question can be asked of how much of your benefit has been used to date.  The treatment planners will take all this information and then will devise a treatment plan for you based on the doctor’s recommendation of what needs to be done to work up the cost for you.  If the information is not accurate the cost can be way off.  What is given to you is an estimate of what the cost will be as the actual determination of what is paid by the insurance company is what they choose to pay as they can downgrade the procedures to pay a cheaper amount which leaves you to pay the difference.  The dental office has no control over what the insurance company does end up paying, but remember this is your contract with the insurance company.

In Network Vs. Out of Network

The other thing to keep in mind is being in network versus out of network.  Some insurance companies have no out of network benefits, meaning if you see a provider that is not contracted with the insurance company, they will not pay anything on your claim and you will be fully responsible for the charges.  You are always responsible for your charges. ce

There are thousands of dental plans in existence and your dental office does not know them all.  Every employer can have different nuances and it is your responsibility to have your dental insurance information just as you do for medical insurance.

Dental Insurance companies do not like paying claims.  They certainly act like they know more about dentistry than the dentist treating you.  They will second guess and find any excuse to deny or downgrade the procedure so they don’t have to pay, but you, the covered entity not only has to pay the premium, but that which the dental insurance company does not pay for.  Dental insurance is about partial reimbursement.   Most out of network payments are made to you, the patient, not your dentist who performed the procedure in which you will then have to send the payment to your dentist.  The dental insurance companies do their best to push the costs to the patient while still collecting the premium.

There are also waiting periods with most plans before the company will begin to pay for some procedures.  Usually diagnostics and prevention (x-rays and cleanings) are available at the beginning of coverage but it can be 6 months to a year before coverage will commence on restorative work such as fillings or root canals.  Most plans do not cover implants and cosmetic dentistry is never covered.

How to Get Faster Service

Dental Insurance companies are much faster answering the phone for their members than they are for answering the provider’s calls in their network.  It is much easier for you to come prepared with your insurance information by calling member services of your plan than it will be for your provider trying to get your information.  If you wish for faster service at your dental office, it is important that they have access to your plan information so the office can check if you’re active and find out how much of your benefits you’ve used to give you a better formulated treatment plan in terms of letting you know your estimated costs.