Tooth insured or not tooth insured?!

Today I feel like talking about dental insurances. Have you ever wondered how they typically work? Are they covering 100% of the dental treatment recommended by the doctor? Are their parameters to accepting or denying clinically recommended treatments in accordance with high quality doctors’ final diagnosis? Can you use the total amount of my policy if you have a sudden emergency treatment on a single tooth?

What do dental insurances really cover? Among patients’ most common phrases you find; “I’m sure my insurance will take care of it”, “I have $2000 a year to freely use”, “If I have two root canals, 3 cavities, 2 crowns and 1 bridge to do, what is the best insurance to apply for?”

Do insurances really work/benefit/save? Are insurance companies’ allies or enemies? Can it be true that insurances often dictate and overrule the dentists’ recommendation and deny recommended treatments  that is doubtfully in the patient’s best interest such as denying an implant versus a bridge, or a fixed bridge versus a removable partial denture?

Among the categories of dental insurances you find your PPOs, HMOs, Discount plans and government subsidized Medicaid. Discount plans have a set fee for service and the dentist has to be under contract with the plan to accept the often very low disbursement fees, a fair amount of highly trained- quality dentists don’t accept it, limiting your options. Government subsidized Medicaid helps in emergency treatment such as extractions, removable partials and full dentures with pre-authorization. Unfortunately most times patients opt to extract rather than safe via root canal/crown a tooth, because they have no financial means and the insurance definitely does not cover.

PPOs work by having a top allowance per policy such as $2500, $2000, $1500, etc. this total amount is then divided further into categories and specialty treatments. Each category gets a percentage of coverage. For example preventive treatments such a x-rays, exam and 2 regular prophylaxis cleanings a year are 100% covered, and once every 3-4 years a full mouth deep cleaning is mostly covered 60-80% according on insurance.

Most patients think that by having a cut taken out from their weekly paycheck –full of genuine hope– automatically assume they signed up to the best insurance that will cover any emergency visit or treatment due to a chronic neglect caused by skipping dental visits and often compromised oral hygiene.

That being said lets supposed you went to the dentist after 3 years of procrastination. You finally arrive and they take full mouth x-rays, the doctor exams you and recommends a deep cleaning because of the amount of calculus/tartar deposited under the inflamed gingival pockets that have developed around the teeth due to bone recession and overall periodontal disease. The dentist also says you have to extract a tooth and the best replacement option for your young age, he firmly recommends a single tooth implant which avoids shaving down the adjacent teeth for a porcelain bridge.

In your case with a $2000 PPO policy, the insurance would most typically cover 100% of exam, x-rays and even extractions; unless surgical/impacted. This can add up to around $400 which is then deducted from $2000. The insurance, however, would only cover 60-80% of the deep cleaning which is done in 4 quadrants of the mouth ranging from 125-300 per quadrant according to the fee schedule contract between your insurance and dentist rendering treatment.

On the low end, the complete deep cleaning of 4 quadrants of your mouth, would add to approximately $500. You are looking at having to pay 20% of the $500 for the deep cleaning. The bad news comes in, when they now tell you that your policy does not cover implant placements at all. However, the PPO policy does cover 50% of a bridge, ONLY if the tooth has been lost within the time you had the policy. Here is the most infuriating missing tooth clause that no one talks about. It is indeed the biggest nightmare for most dentists and dental managers.

How do you tell your patient that they really do need a replacement of a missing tooth for proper functioning, occlusion, digestion, avoiding migration, but their insurance denies to pay simply because it was lost prior to being insured? What ever happened to the new OBAMAcare and eliminating the pre-existing conditions from insurance policies? Are we being punished for procrastinating on our dental care? Don’t they still cash our money religiously from paychecks whether or not the dentist visit is met?!

Luckily in your case, since you have just extracted that tooth, Instead, they would help you pay 50% of a 3-unit dental bridge to cover the new missing space and in result, both of your adjacent virgin teeth would be filed down to fit crowns. Was this the doctors’ order? By now, even if the bridge convinced you, out of pocket money would still be necessary.

But what if I had never used my insurance? Does it roll over? And the answer is no. you lose your restricted benefits every calendar year.

HMO’s work completely different and take away even more control than PPO’s. You can only go to certain doctors in their network and have a fixed fee schedule that patient is responsible for. For cavity fillings dental insurance representative fail to inform the patient that only AMALGAM fillings are covered and that they always have to pay for the upgrade fee difference to have white color fillings placed. The patient always has to pay out of pocket even when they neglect to state that upon selling the product. the same happens the same when the patient falls into a more advanced gum condition that would require deeper cleanings different from the covered prophylaxis. Once again the patient would have to be responsible for the offices fee, because the HMO’s plans don’t cover anything deeper than a regular cleaning. Prophylaxis cleanings fail to reach deep enough to   properly eliminate the tartar and plaque under inflamed bleeding gums that heal severe gingivitis and periodontal disease.

Even when PPO’s allocated money total is divided into % coverage in the different specialty categories and  dental procedures, it allows the freedom to choose any dentist from all networks. A dentist-patient bond is a very intimate relationship you have to build in order to find the chemistry to feel at ease.

Did you know that a large portion of dentists drive their practice collections solely on what dental insurances cover? Often times neglecting to even mention what the next best treatment plan option is for you, in fear of rejection on a more costly yet more functional/esthetic option? Most times patients have set their minds to solely accept the treatment that is most covered by their current insurance policy. But fail to wonder if these large companies are stopping to really make a beneficial decision based on their unique dental status condition.

As a dentist I mindfully see my every patient for what they are, human beings needing an upgrade from their current oral condition. Whether they have insurance or not, I lay down the options from ideal not so ideal and I leave it up to their judgement to decide for the best treatment. I spend my time educating them about the different types of prosthesis and materials available. I question them on their goals and always try to match their expectation to what gets delivered. I don’t pay attention if they have insurance or not, I simply walk in and recommend what I feel and know in my gut the patient will be satisfied and functional in the long run.


Dr. B

Dente I have created this interactive space especially for you, the dente patient. One of the most gratifying things in life as a dentist, is to effortlessly educate while answering doubts and eliminating most typical myths about dentistry. I have a passion for the building blocks of dentistry and it comes as second nature to want to give detailed explanations to my patients as we discuss the treatment plan options. I’m a firm believer that if the patient understands the intricate science behind their oral status, a confident decision is an organic result. I am a practical dentist that is actively looking for the best option to treat your needs. Technology is rapidly changing and there are many options one has to have into account in order to provide for the best long term esthetics and function. Our simple philosophy is to serve you while getting you to that comfortable place where you genuinely smile from within.

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