Talking Facts and Dispelling Fiction About Dental Insurance: Here’s What You Need to Know

The way dental insurance works—whether you have an employer-sponsored plan or an individual plan—tends to be perplexing and frustrating for patients. We have many years of experience working with dental insurance and our goal here is to help you understand the process and hopefully lessen the confusion. We want you to be informed!

For purposes of this discussion, we are referring to dental plans with regard to general dentists, not specialists.

Nine Insurance Facts You May Not Know

Fact 1: Dental insurance is not true insurance.

Unlike medical insurance, dental insurance does not provide significant protection against unexpected or unaffordable costs. Medical insurance often pays a large portion of expenses after a deductible or co-pay has been met. Dental insurance, on the other hand, is designed to be only an aid or supplement to help with your dental care.

Insurance companies spend a lot of money on marketing and promotion, giving customers the impression they’ll pay up to 80%, even 100%, of their dentists’ fees. Despite what you’ve been told, we find that many plans cover anywhere from 40% to 60% of an average dental fee. For the same procedure, some plans pay more and some pay less. Ultimately, the amount paid by insurance is determined by how much your employer paid for the plan. The less the employer paid for the insurance, the less you’ll receive in benefits.

Fact 2: Dental insurance benefits and maximums are too low.

It has been our experience—and that of many dentists—that insurance companies often tell patients their dentists’ fees are above “usual, customary, and reasonable” (UCR). What they should be telling you is, “Our insurance benefits are too low.”

Dental insurance companies seldom upgrade their UCR fees, even when the cost-of-living index rises.

Fact 3: Many routine dental services are not covered by insurance carriers.

You would think insurance companies would be eager to provide coverage for less-expensive, less-involved, more-preventive procedures such as multiple cleanings, deep cleanings (periodontal root planing and scaling), and small fillings to help patients avoid more costly procedures in the future.

Unfortunately, this isn’t the case. For example, some insurance companies don’t allow coverage for deep cleanings until the patient’s periodontal disease has progressed to the point of bone loss. Why not be proactive in preventing dental disease that affects your overall health?

Other plans will limit how often a single tooth can be filled—anywhere from two to three years! If we place a filling for you and 18 months later you break the filling or develop new decay, that type of plan will not cover another filling on your tooth for another six months. By that time, your tooth could become painful or infected or break off even more and require a root canal and a crown—procedures that will cost even more.

Fact 4: Insurance companies often “down-code” or apply an “alternate benefit” to procedures in order to pay less.

A very common example of this is when your plan will only pay for a tooth-colored (composite) filling at the rate it would pay a silver (amalgam) filling. Or it will not pay for a composite on molar teeth—so identical composite filings on two side-by-side teeth will be paid at different rates if one tooth is a molar.

This is the part of your plan that says molar teeth are “downgraded” to amalgams. Most dentists no longer use amalgam to fill teeth. We want to provide you with the best dentistry—the same thing we want for ourselves. Your insurance company wants it to be cheap. In today’s world, patients do not want amalgam fillings. Do the insurance executives want amalgam fillings in their teeth?

Fact 5: Dentists do not charge different fees to different patients for identical procedures based on whether or not they have dental insurance.

But every insurance company has a different schedule of “allowable” or “covered” fees it will pay for identical procedures based on the geographic location of the dentist.

Insurance companies use actuaries to determine their “allowable” fees, called UCRs, based on data they compile about a geographic region of the country, the number of procedures performed, cost of living that they’ve determined, and other variables.

What is UCR? “Usual, Customary, and Reasonable” is the term used by insurance companies to describe their maximum “covered” fee—the amount they are willing to pay for a particular dental procedure.

Once the data is collected and analyzed and an average fee determined, the insurance company will then base its UCR on a percentage of that average fee—anywhere from 5% to 100%.

Furthermore, the wording they use to explain to you—the patient—the reason for a benefit coverage or denial appears to be designed to create an adversarial relationship between you and your dentist. Two common explanations are, “Your dentist may be charging too much for this procedure,” and “This procedure was denied because we found it unnecessary.”

Is the insurance company performing your dentistry for you? Is it qualified to diagnose and treat your dental needs? Remember, the insurance company is there to make a very big profit. The less it pays out, the higher its profits. Meanwhile, you’re still paying your premiums.

Fact 6: Dentists who join dental insurance networks do so to get more patients coming into their practices.

There are no other benefits for the dentist to join. There are, however, plenty of negatives. (We know; we were once part of a dental network.)

Your insurance company will encourage you to use a “preferred provider” as a way for you to save money. They’re “preferred” because they’ve entered into a contract with the insurance company agreeing to write off part of their fees—meaning the insurance company pays out less. In some cases, the “preferred” provider is forced to write off the entire fee if the insurance company “deems” the procedure “unnecessary.”

Reduced fees might sound great to you as a patient, but in order to provide care with such dramatically reduced reimbursements (often 50% to 60% of the dentist’s actual fees), in-network dentists often struggle to maintain the quality of care they want to give their patients.

The result can be fast, impersonal appointments, cheaper materials and supplies, and the need to raise fees in order to make up for the write-offs. The higher fees directly affect the patients who don’t have dental insurance because they’re going to pay a lot more for the same procedure, in the same shortened appointment time, using the same dental materials.

If you’ve ever been a patient in a corporate-owned dental practice, you’ve experienced this. The more networks a dentist joins, the more patients he or she has to see in a single day to make up for the discounted fees.

We’ve all experienced the effects of insurance interference in medicine; we really don’t want this to happen in dentistry.

Fact 7: Dental plans in the 1960s allowed a maximum benefit of $1,000 per year per person. Today—more than 50 years later—the average plan still allows only $1,000.

Premiums have increased. The costs of supplies, materials, technology, staff, and utilities have increased. The cost of owning a business has increased, and the cost of living has increased—all significantly in 50 years. But the average annual maximum for a dental plan continues to hover at $1,000—not enough to cover a single root canal at 80%.

Fact 8: If your insurance plan is a PPO, you can choose your own dentist and are not forced to see a network dentist in order to receive benefits.

Despite what the insurance company tells you, dental benefits will be paid when you choose your own dentist in a PPO plan. Something you probably don’t know is that non-network offices—like ours—are often “allowed” higher UCRs than in-network providers for the same procedures. But an insurance company will always encourage you to see a network provider because doing will save money for the insurance company.

Fact 9: When it comes to insurance, we’re on your side!

We will do everything we possibly can to help you maximize your dental benefits every year—and we are happy to do so. If you have questions about your dental plan, we will help you find the answers.

Your dental care is why our practice exists. We strive to deliver high-quality dentistry for our patients with skill, empathy, care, and a gentle hand. That’s why we will never allow an insurance company to dictate what we can and cannot do when it comes to our patients!

We want you be healthy, happy, and smiling—and we want you returning to our practice for many years to come!

A Few More Interesting Things—Just So You Know

• By law in North Carolina, insurance companies have 30 days to process claims. Most have fast turnaround times but others will take several weeks to send the reimbursement to our office. A very few still use the trick of processing the claim on the thirtieth day in order to delay payment as long as possible.
• We file claims electronically and most payments are sent to us electronically by direct deposit. Some insurance companies pay by virtual credit card and others still reimburse by physical check.
• A few insurance companies (like Blue Cross Blue Shield of NC and some Delta Dental plans) have chosen to only reimburse patients or policyholders when they visit non-network dentists. If this applies to your plan, we encourage you to talk to your company’s benefits administrator to have reimbursement (called assignment of benefits) paid to non-network dentists as part of the contract. Doing so is a benefit to you and to all patients who wish to choose their dentist, and it’s actually a cost saver for the insurance company.
• If you receive an Explanation of Benefits (EOB) stating the “dentist failed to provide requested information,” or “we need information about additional insurance,” or anything similar, please contact us. Chances are, we included the information but the claim was processed incorrectly by the insurance company, thrown out of the system as a denial to meet a quota (yes, they actually do that), or requested as a delay tactic to stall payment. Every time your insurance company sends one of those letters, it gains another 30 days of processing time, which means another 30 days of delaying payment!