Wednesday, October 11, 2006

Dental Insurance-Part 2: How it really works

Most people really don't understand their insurance coverage. They usually assume if they pay the premium, they won't have to pay anything. The reality is that insurance is so complicated and is some ways deceptive, that most people don't realize what companies are doing. Deductables, percentage of coverage, delay in payments, downcoding (changing) of procedures to reduce payment, not covering certain procedures at all. All this can set up expectations of complete coverage that cannot be met. Your policy is so complicated you really didn't realize what has transpired. Although he can guess, the dentist cannot definately tell you what your company will pay. Every patient in there has a different policy with different terms. Even then, companies often change their coverage terms. Also, the insurance company will not send you, the patient, the claim check, they send it to the dentist. So generally, you do not pay the whole bill when you have the treatment done like most regular purchases. You may be asked to pay an estimated copay or simply have the dentist file the claim and wait for a bill later. Here is the example similar to the one I mentioned in Part-1. Confusing isn't it:

You go to the dentist and your child has a "cleaning", x-rays, a complete examination. Then he has a white filling and a crown with a pulpotomy with a little laughing gas to relax him. Not a lot of work, but at least you got the problem solved. Your dentist files your insurance. You pay the known deductable. Then, after a few months, you get a bill from the dentist for the amount not covered by the insurance. You are confused. You knew about the deductable, but the rest is pretty much covered, right?

The cleaning, exam and x-rays were covered at, say "100%", and you had a $50 deductable on the remaining treatment with 80% coverage on the amount after that.

What the insurance company will actually do, is downcode the white filling to a "silver" filling (a paperwork trick that pays on a less expensive procedure you didn't actually have done). They reduce the total "fee" on other procedures to their predetermined (ie. made up) "fair" amount, then pay 80% of that, not the original amount. Then, you had forgotten, they only pay 50% of endodontics (the pulpotomy), and they don't even cover the laughing gas at all. Oh, yes, the deductable. It adds up. Your other child (say, from your first marriage), is covered under another plan that has different coverage, so you are confused at the difference in coverage. You get a bill from the dentist. Are you mad? Sure. Where should that anger be targeted? Just remember the dentist hasn't been paid in two or three months, has paid staff to file the claim for you and refile it when the insurance co. "lost" the claim. They tried to estimate the cost for you in the beginning and offered financial arrangements for the remaining amount. They deal with thousands of policies and are doing their best to sort it all out too. What this has done I fear, is breakdown some of the trust in the dentist patient relationship. Not from anything they have done, but from the outside force of the "middleman" of insurance. Some level of confusion and misscommunication could lead to more of an advisary type relationship more common in car dealerships. I hope not.

Insurance companies are in the business of insurance to make money. This is not a bad thing. In most circumstances, their customer is not the patient but employers. What you hopefully get is peace of mind for unexpected expenses. Is it worth it? As I mentioned before, dental services are a statistically predictable non-catastrophic expense. If you have it, well of course use it. Otherwise, each person will have to make up their mind if it is really worth it. I don't want to sound too down on insurance. As I alluded to earlier, some people can benefit from insurance. Some simply cannot afford to pay the entire bill out of pocket if the treatment needs are extensive. I just don't like to see the parent of a patient decline treatment for their child for supposedly financial reasons because dental insurance doesn't cover 100% of the treatment cost. Then, they take a call on their cell phone and drive off in their new Lexus. Priorities.

Know what your insurance policy actually covers, and understand it will be confusing. Remember, the dentist is just as much of a victim of this confusion as the patient. Dentists, remember the patient doesn't always have all the details of their policy that they didn't even pick. Their employer is the one who asked for the cheapest policy. If everyone has some tolerance and understanding, the trust that is the dentist patient relationship can withstand these outside forces.

Dental Insurance-Part 1: A Good Idea?


Anonymous said...

Thank you so much for your insight on this process. I am flabbergasted everytime I go to the dentist and am hit with a $800 bill. My kids don't have particularly "bad" teeth, but do require the occassional filling or sealant. It's funny that you used the used car analogy because that's exactly what it feels like. My dentist wants his money up front and if you can't come up with the money and schedule the procedure within 75 days, he's gonna charge you for another exam and start the process all over. How do I know when I'm getting what I "need" or when I'm getting bamboozled?

Dr. Dean Brandon said...

He (the dentist) has probably been burned in the past by patients who get treatmet done and do not pay, -especially for expensive procedures where he might incur a lot of cost. You cannot exactly reposess a crown. Still, I would hope our profession has limited the amount of unscrupolous professionals out there. BTW, Delays in treatment often mean the treatment suggested may have changed. ie a sealant delayed too long, well there may be a small cavity there now...

umakanta said...


My son is of 4 years and 8 months. He had cavity on his 2 upper front teeth(middle two teeth). Doctor cleaned the cavity and had filled with filler. But after 1 day the filling materials came out. Now the doctor is recommending to to put crown/cap on both teeth. Is that a good recommendation? What are the process for putting crown on teeth. Is there any drill down needs to be done? I really scare about it. Please help and suggest.
The gap between two teeth is not that much, it could be 0.2 cm. and he only gets pain when he eats something and bite on those front teeth.

Dr. Dean Brandon said...

Crowns are often done when fillings are larger or hard to retain. Read more about crowns here on the blog linked over there on the right column under fillings and crowns.