Many times we get the questions:
Why doesn’t my insurance pay for this procedure? Why did the insurance company pay less for this procedure this time than last time? Why are you not on the list of providers for my insurance? Why do you not accept the PPO plans offered by my employer? Why can other offices accept the plans offered by my employers and you can not? And many more along the same lines.
Dental Insurance is really more accurately described as Dental Benefit:
INSURANCE: A system to make large financial losses more affordable by pooling the insurable risks of many individuals and business entities and transferring them to an insurance company or other large group in return for a premium.
INSURABLE RISK: Risks for which it is relatively easy to get insurance and that meet certain criteria. These include being definable, accidental in nature, and part of a group of similar risks large enough to make losses predictable. The insurance company also must be able to come up with a reasonable price for the insurance.
In dentistry, “insurance” is expected to cover not only the accidental situations, but the PREVENTABLE and AVOIDABLE situations and therefore is more accurately described as a “benefit”. Just imagine how expensive your car insurance would be if they covered oil changes and tire repair.
Who determines the benefit?
Every employer who offers dental insurance to their employees has most of the control over what they want covered for their employees. They may not have very many options themselves when choosing a plan for their employees depending on the state they live in, but of the choices they do have, they are the last say, and they choose what the employee gets as a benefit. So next time a procedure is not covered by your plan, you need to ask your human resources personnel what other plans are available and if there are better options. There may not be a better option, but it is worth asking.
How is the amount of coverage determined?
Unfortunately, dental benefits are much like they were in the 1970’s. Procedure costs have risen through wage, supply, logistical, and other factors to upwards of 4 times the cost it used to be, but dental benefit maximums have pretty much stayed the same as they were way back when they were first introduced.
1970’s benefit of $1000.00 per year would now translate to $4000.00 per year benefit.
Other reasons a procedure isn’t covered:
Preventive vs Periodontal Disease: Many insurance companies will cover two preventive cleanings a year at 100% or two Periodontal Maintenance appointments at 80% per year. The insurance company will pay more to prevent a disease than to help correct the problem once it is there. Periodontal disease is 100% preventable and once the disease is present the insurance companies expect their clients to take on some of the burden of treating the disease. You pay for two appointments and they help with the other two. For this very reason, keeping the disease away is extremely important; right up there with not wanting to lose your teeth. As a dentist, what determines preventable vs periodontal? Any signs of the non-reversible disease process during an exam is considered periodontal.
In other words, if it is reversible it is preventable. If it is non-reversible it is no longer preventable and can only be maintained.
Insurance is a benefit and nothing more. It was never intended to pay for all your dental care needs. However, it is your benefit and maximizing that return for you is something we gladly do!