Many people don’t realize that dental insurance can be quite a bit different than medical insurance and part of that difference is with the limited coverage provided by many dental insurance plans. Often times the patient’s coverage does not include protection against aspects of the disease process, which is important for follow up treatment.

Limited Coverage

Insurance companies are in business to make money. Therefore everything has to be set up on actuarial basis so that they can charge enough and yet not have to pay out too much. What that means to the patient is that if you rely on your insurance alone for what they will cover or pay for, then there is always the potential that you are deteriorating in your overall oral health. There are procedures that are not covered by insurance that are necessary to remain healthy. Insurance plans have limitations on all preventative procedures and some people require more than the average in order to stay healthy. If you only do what the insurance will pay for, yet you require more, then that means your health is going to suffer over a period of a few years.

The first insurance that came around somewhere in the late fifties/early sixties had annual maximums around $1000 – $1500. The great majority of insurance plans that we see today still have the same maximums. So it doesn’t go very far anymore. Basic inflation suggests that maximums should be increased to $5 – 6,000. For this reason, dental insurance just doesn’t seem to go very far-you fix a couple of teeth and the maximum is reached. Patients often times need more than what is covered in their dental insurance plan. Insurance is certainly beneficial.

Those who only go to the dentist because they have insurance and a 3^rd party is going to pay for it may not value their oral health highly enough to put money out of their own pocket for it. So they are going to do the minimum…and if you do the minimum that insurance will cover, that is usually not enough for many people and their health will deteriorate. For example, dental insurance does not always address problems that need treatment, such as worn dentation. Many insurance companies will not pay for any of the newer procedures that are available in dentistry, and some of the dental insurance companies are still downgrading certain procedures such as the teeth colored restoration on back teeth. They say they won’t pay for that-they will only pay for silver filling because it is cheaper. Some insurance companies have a clause in the plan that offers “the cheapest alternative benefit”. There are also all sorts of limitation on pre-existing conditions.

One of the biggest issues we run across is the patient thinks the insurance company is paying 100% of 80%. Actually that percentage is determined by whatever fee the insurance company dictates that they think a specific procedure is worth, at an average for the particular area the patient is in.

Treatment dictated by insurance coverage.

Another important issue with insurance is if a dentist does sign up with some plans that try to control the maximum payment that they will make on certain procedures, then in order to make a profit those dentists are forced into a clinic situation where they have to use multiple chairs and see as many people as possible and the patient finds themselves in a chair waiting, and waiting, and waiting for the dentist to get done with the previous procedure so that they can get on with yours and somebody else’s treatment at the same time. I just found that to be a method of treatment that does not predispose to the highest quality results for the patient. One thing that really suffers in this system is the communication process-the patient doesn’t get enough information to make an informed choice about what kind of treatment they are getting. They are not being educated when the dental professional chooses the quickest way to get started drilling on the tooth in order to get the restoration done that the insurance will cover, because they may not be getting paid enough to spend the time to educate and set goals in the treatment plan for the patient. Insurance driven dentistry is also doing a lot of full coverage crowns that don’t need to be done and it would be preferable to do a conservative type restoration that covers part of the tooth instead of the whole tooth. These procedures are being done because they are covered by insurance. It would take more time to explain to the patients the benefits of the conservative restoration and that it costs more and it is easier to just offer the full coverage crowns to execute the procedure and collect the insurance payment. Many times the patient doesn’t even realize that they have other options available to them.

The patient should have the opportunity to get involved like they should. Because our job really is to educate the patient to the point where they can make choices based upon what’s important in their life- instead of dictating treatment-because there are so many options today and some of it, quite frankly, is elective. The patient needs to determine whether it is important to them or not to spend that money at that particular time in their life. It changes for people sometimes based on what is going on in their life.

Dental insurance is set up on averages.

These restrictions implemented by insurance companies can sometimes create hostility between the patient and the dentist because they look at their plan and think the dentist is charging too much. However, the insurance companies don’t know how much it cost for the dentist to run their practice and to use the best laboratories, materials, and etc. Insurance-driven dentistry can lead to mediocrity of dental care. While this type of dentistry is acceptable for individuals with exceptional oral health, in a curve of oral health there will be those who need extra dental care to prevent or manage poor dental health. The insurance companies are designed for those who can get away with average to little dental care. They can not afford to make their plans to consider those on the other end of the oral health curve because that would not be profitable. People should be ready to spend the time and sometimes their own money to maintain good oral health, in spite of what the insurance companies will or will not cover.

Health-Driven Dentistry

I often ask patients, if I see something in your mouth that is not correct and needs some attention that’s not covered by insurance do you want me just to ignore it? Obviously we can’t do that-I’m going to have to do something about it. The question is, do you want to be healthy or do you want to rely on your insurance company to take care of you. You should be careful if you are relying on the insurance company alone, because your health may not be their primary concern and if you rely on other people to take care of you they can become your tailors and create problems for you in your life-in this case your oral health.

We try to help patients set goals for their health. We do not focus on insurance when going through the process of determining how healthy the patient wants to be, how pretty they want their smile to be, and what is most important to them? Sometimes, when money is the driving factor, we look at how can we get them to a basic healthy state and then help them maintain that. We also look at how the insurance can best be used to help support that. However, it is not the driving factor. We don’t decide that we are going to clean your teeth every six months because that is all the insurance will pay for, when you may actually need periodontal cleanings every three months to stay healthy. If the insurance company will only pay for silver fillings on the back teeth, and we don’t think putting silver fillings back there is the best restoration method, then we are not going to put them in. It may cost a little more for those patients who want to stay healthy, but there are certain things that I in good conscious can’t do, just because the insurance company would pay for it.

There are a lot of different insurance plans out there, and they have preferred providers. Individuals will call the practice to ask if I am on their insurance plan. The answer is: we will help process their insurance to help them get the maximum amount out of it but we can’t sign up for those plans where insurance companies gain more control of the patient’s treatment because a third party who is doing something for profit is certainly not going to agree to do what is best for the patient if it means their going to lose money.

One-Patient-At-A-Time Dentistry

We treat one patient at a time. We want to spend the time goal setting and examining where they are, how they got there, and where they want to go. Instead of just treating an immediate problem, we want to find out what caused that problem to occur and what can we do to prevent it in the future. And insurance is set up for procedures, how many procedures can you do. This process becomes more about numbers and less about the individual’s needs. Removing insurance as the main focus, allows us to spend time with patients who are truly concerned about their oral health.

Preferred Provider List

Our practice is not on a preferred provider list. Many times when patients come in and we are not on their preferred provider list- they still get reimbursed the same amount from their insurance company. In some cases the insurance company is set up where they penalize the patient for going to an out of network dentist but the majority of the time we find that if someone is getting significant treatment of any kind, when they hit the plan maximum, that is all it is going to pay no matter what.

Effects of minimum care for teeth

We have seen all kinds of patients who had previous dentistry done that was dictated by only what insurance would cover. One tooth here and one tooth there…instead of a comprehensive plan considering all the final goals to treat your entire oral health. There will be restorations on different types of materials, crowns done at different times, different colorations, without consideration to the entire mouth wearing down. That needs to be addressed before putting in individual crowns. Insurance driven dentistry, forces you to ignore some of the major issues going on in the mouth (i.e. taking care of TMJ before starting restorative treatment). Periodontal disease is another treatment that can not be effectively addressed by only regular 6 month teeth cleaning.

Long term the patient will save more money by addressing all the issues early. And the insurance company may not allow a reimbursement for certain treatment of bite problems or TMJ problems. But if you ignore these, in some cases it can turn out to be a major investment later on to restore your teeth as they have worn to much or sometimes needs surgical intervention, such as for TMJ, that could have been avoided. So it is not only more expensive but it is a deterioration of your health that can occur…and years of discomfort.