For some years now I have been trying to figure out exactly why dental insurance has so many people confused. There are all the ADA codes for each procedure, in-network and out-of-network dentists, co-pays, deductibles, waiting periods, major, preventative, etc. All these terms make my head hurt...and I am a dentist. I can only begin to imagine how mind-numbing figuring out dental insurance must be for the average patient. I have two dental offices and have been practicing for several years. We are in-network with certain dental PPO insurance plans (for more information on the different types of dental reimbursement please check out my blog), and I would like to try to clear the air.
The problem arises with the misnomer. It looks like insurance, it walks like insurance, it sure talks like insurance but dental insurance is not insurance at all! Insurance is a risk management strategy that hedges against uncertain and potentially catastrophic loss. Any practicing dentist will tell you that dentistry is not catastrophic. Dental insurance is more of a discount program whereby the consumer (or his/ her employer) pays a monthly premium to the dental insurance company. The company, in turn, negotiates reduced fees with a dentist and offers its consumers some kind of hook which usually takes the form of “two free cleanings per year.”
Two free cleanings: A Marketing Gimmick
Every dental procedure has an assigned code that is used to communicate the procedure completed to the insurance company. It is important to note that not all dental codes are covered by every insurance company and those codes that are not covered are often not subject the “negotiated rates.”
The code for the two free cleanings is D1110. The American Dental Association who puts out the codes defines D1110 as a coronal fine scale and polish, which is the equivalent of a thorough polishing and plaque removal of the whites of your teeth. A D1110 does not cover scaling and root planning which usually involves the use of an ultrasonic tip to remove tartar (calculus) from the root surface or below the level of the gums. If you have radiographic evidence (can be seen on x-rays) of bone loss or sub-gingival calculus, dentists should recognize the signs of periodontal disease and prescribe a deep cleaning which bears a different code. This is no longer a free cleaning, but the deeper cleaning is the right treatment for the condition. Oddly patients are seldom upset that they have just been diagnosed with a disease but are more concerned that they are not getting the “two free cleanings” that sold them on dental insurance.
Another often misunderstood aspect of the “two free cleanings per year,” is the fact that the actual language of the insurance contract provides for one free cleaning within a six month period. This is another way for the insurance company to deny a claim if the patient accidently gets two cleanings 5 months and 28 days apart. Several other hidden clauses allow dental insurance companies to deny claims like pre-existing conditions, or lifetime maximums (common for orthodontic codes).
Risk Mitigation: Who is Really Protected?
Similar to the deep cleaning, almost every other dental code has a co-payment associated with it where the patient pays a percentage (dictated not by the dentist but rather by the dental insurance plan chosen by the patient or their employer) of the negotiated fee and the insurance company picks up the difference. That is up to a yearly maximum of $1500 (some of the better insurance policies generously offer a maximum of $2000). This number has remained relatively unchanged since the 1970’s despite tremendous advances in the field of dentistry as well as the rising cost of dental services.
The fundamental difference between dental and medical insurances is that the more services you need in medical, the more your insurance picks up after you have met your deductible. In dental however, you meet your deductible and then the dental insurance company’s risk is capped at $1500 leaving the patient to pay 100% of the rest of the treatment needs. So consider that the maximum benefit available to you, the patient, is equal to the maximum annual coverage of the policy.
Wait for it…
Tucked away into almost every dental insurance contract is a “ waiting period clause.” This clause cleverly ensures that the insurance company receives premium payments from the consumer for a minimum of twelve months before any significant dental procedures (referred to a major procedures). The consumer cannot visit a dentist, find out they need a lot of dental work, go out and buy “dental insurance,” and return immediately to have the treatment rendered. Most disease processes in dentistry do not wait! That cavity keeps getting worse, and quickly. Soon the patient needs more extensive procedures like root canal treatment or extraction of the tooth and its replacement which proves far more costly, even with dental insurance, than simply having a filling placed and paying for the entire service out of pocket.
A Dentist’s Perspective: The Relationship Killer
As a dentist, you sign up with a dental insurance company to become “in network” in order to bring more patients in to your practice. It is important to remember that these patients are paying a reduced fee and can often take up the majority of your available chair-time. Let’s also not forget that you have to hire at least one more employee just to deal with the tremendous joy of submitting claims, re-processing denied claims, and entering insurance payments.
Probably the most frustrating aspect of dental insurance is that it puts up barriers (often financial) in the doctor-patient relationship. When a claim is denied, there is no one putting their credentials on the denied claim. So why is it that the providing dentist has to submit his credentials to the insurance company? Why wouldn’t the insurance company at least pay what they would ordinarily cover on one procedure towards another procedure that the patient needs or chooses but perhaps costs a little more? Shouldn’t patients be able to decide what they want done to their bodies?
Dental insurance companies are third party payers who collect money from consumers, turn a tremendous profit, and pay out as little as possible to the treating dentist, adding very little value along the way. The additional volume takes away from the quality time that can and should be spent on getting to know the patient and formulating a treatment plan that best address his or her needs.
Dental Insurance: An Unnecessary Evil
Here is the simple truth behind it all, dentistry is affordable! Most people would be better off if they simply spent their premiums in regular, routine, preventative dentistry. If the treatment plan is involved and expensive, chances are the costs far exceed the paltry $1500 of coverage and the patient finds other means of affording the care.