Unfortunately, these days we live in a world ruled by insurance. Between our individual policies, home policies, car, health, life, and others, we spend over 30% of our income on insurance coverage. No wonder that we want a return on our investment and count on paying little out of pocket when we use our insurance policies.
Dental insurance benefits are different from medical and are probably the most commonly discussed topics in our office. In comparison to medical insurance, the cost of dental coverage is fairly low ranging from $10-50 per month. The actual benefits can be customized by the employer’s negotiations with the insurance company and vary widely. Within the same company, you can often choose from a variety of dental plans and your coverage will depend on the amount of premium you are willing to spend per month. Most dental plans have a yearly maximum of $1000 to $2500 and any dental work beyond that number will be an out of pocket expense. In addition, some plans will also have a deductible that will have to be paid before any of the costs will be covered by the plan.
DMO plans (like medical HMO) are usually the least expensive plans that limit the patient’s choices on which dental providers they can see. Dental offices must abide by their set fees for each procedure. Unfortunately, those fees are often so low that only corporate dental chains will be on the lists of choices since privately owned offices often cannot afford care at that fee.
PPO plans have both IN NETWORK and OUT OF NETWORK benefits. You can see any dentist you would like and they will pay the dentists certain percentage of your dental procedures. If your dentist signed up with your particular insurance company, he or she is IN NETWORK and bound by the contract to accept the insurance company’s rates. If you choose an in-network dentist, you will likely have a lesser copay since your dentist must abide by the negotiated fees. If your dentist is NOT signed up with this plan, you can still see them and collect all your insurance benefits the same way. However, you will need to pay your dentist the difference between the fee the insurance company established for each procedure and the fee your dentist set. If your insurance has good benefits, there should be little difference for in and out of network providers.
Let us look at an example. Your dentist feels that a reasonable fee for a particular dental procedure is $100. However, a PPO insurance company set their fee at $50. If your dentist is IN NETWORK, he or she would have agreed with the insurance company to accept $50 for this in exchange for placement on their distribution list and benefit of getting a larger volume of patients. If your dentist is OUT OF NETWORK your insurance company will pay $50, but you will need to pay the additional $50 to your dental office. In addition, if your dentist is OUT OF NETWORK, insurance companies do not share their actual fees with your dentist. They only share percentage of coverage leaving dentists to guess the actual dollar amount. In the above example, the insurance company might say that they cover dental cleaning at 100%, but not tell the dentist that their allowable 100% is $50. Therefore, when the dentist checks insurance and sees that 100% amount, he or she can only guess at an actual number. It takes insurance companies several weeks to pay most claims.
ORTHODONTIC INSURANCE can be included in your benefits, but sometimes it is an add-on. It is best to check with your insurance before starting orthodontic treatment to make sure that your particular plan has orthodontic benefits. Orthodontic insurance usually has a lifetime benefit of anywhere between $1000 and $2500. If your child needs two phases of treatment, this life time benefit might get used in the first round of braces and leave little or no money for the second phase. Most insurance companies do not have orthodontic benefits past 19 years of age so adult orthodontics is usually an out of pocket expense. In most cases IN and OUT of network benefits for orthodontics only differ by the total amount that an orthodontist is allowed to charge for full treatment, but the benefits are paid out equally for IN and OUT of network orthodontists.
QUALITY OF CARE is what prevents most dentists from signing up with insurance companies. Most dentists are conscientious healthcare providers who truly care about their patients and want to provide the highest quality of care. They want to be able to spend time with their patients, use high quality materials and tools, hire fantastic teams, continue education on modern dentistry, and make long lasting and well-fitting dental restorations. This can only be achieved when they get compensated fairly.
Our office accepts all dental insurances that allow OUT OF NETWORK benefits. We both take and file your insurance for you. As long as your insurance does not bind you to a specific group of dentists, our team is here to help all our patients collect and maximize their dental benefits. We do not bend our fees depending on insurance companies, rather set them fairly to provide highest quality of care. We believe in doing things right and treating all children in our office as well as their parents with respect, love, and time to take care of all their dental and emotional needs. We are committed to our values and will fight for every penny with your dental insurance company. However, we do not allow insurance companies to tell us how to take care of our patients and do not allow their statistical calculations to overrun our clinical judgement.
I hope this helps to clear up some potentially confusing aspects of dental insurance vs other types of insurance. As always, if you ever have any questions, please feel free to reach out to us.
Dr. Lindhorst, Dr. Darsey, Dr. Theriot, Dr. Rodgers and the Heights Pediatric Dentistry and Orthodontics Team
