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What The Dental Office Staff Thinks You Should Know Before You Purchase Dental Insurance

Insurance is convoluted, to say the least. Throughout my years of being a dental office

manager, I regularly get calls from a patient who are looking over re-enrollment forms.

They were un-acquainted about this process it seems as the forms were written in a

extraneous language for them. They also have questions about the whole process like

how do I know what type of coverage I need? What does endodontic mean? Do I need

coverage for that? etc. I had always said that I wish I could hold a seminar for my

patients before they bought insurance. So here are my guidelines for informed

purchasing of dental insurance.

It is my belief that you should approach the purchase of insurance with knowledge of the

following items:

  1. Your dental health
  2. The clauses and limitations of the plan
  3. The insurance company’s reputation for customer service.

Dental Health

A person’s dental health can be impacted by overall body health, personal habits, and

consumption. Conditions such as diabetes, medication-induced dry mouth, as well as,

habits like smoking, poor diet choices, and, refusing to floss also increases the

occurrences of gum disease and tooth decay. It can damage the teeth. Many patients

don’t understand that grinding is not just an annoying habit; it can leads to fractures,

gum recession, and broken fillings. If you have any of the previously described

problems, you may want to consider a more comprehensive plan.

Clauses and limitations of the plan

The day you have a toothache and leave to see the dentist is normally a bad day to find

out you have a six month waiting period on all treatment except cleanings. When

looking at a plan ask the following questions:

  • Is there any waiting period for any category of treatment?
  • Do alternative benefit clauses or exclusions apply?
  • What is the yearly maximum?

Some plans only cover a limited amount if procedures for an initial waiting period.

That me ans in the first months of your plan they will only pay for cleanings, and if you

need any other category of care you will have to cover the cost

Some plans have alternative benefits clauses. Most commonly we see this clause

regarding fillings. This provision states that while your dentist may have performed a

composite filling on your tooth the insurance will only cover the cost of silver filling, and

you will have to pay the difference. The same applies to many tooth replacement

procedures, and your dentist may have placed a fixed bridge or an implant but your

insurance will only pay for a removable partial denture, and you will need to cover the

remaining cost. It’s important to know if your plan has an alternative benefit section

before the work is done. Your plan benefit sheet may say you pay 20% on fillings. After

the downgrade, clause is applied your cost is closer to 40%. You also need to consider

exclusions. Some plans just do not allow composite fillings, bridges, or implants and will

not pay even an alternative benefit. They will only deny the claim and the entire cost

will be yours. When limitations like this are written in the plan, they typically do not get

paid on appeal. Also, watch for age limits on procedures. Many times fluoride and

sealants will only be covered on certain teeth of patients who are in a complete age

range. The age range is different for each plan.

Most plans have a yearly maximum. Commonly it is $1000.00. This means after they

have paid $1000.00 in insurance claims they will not pay any further claims for the

benefit year. That includes services that are naturally covered at 100% such as

cleanings. So if you exceed your benefit for the year and have not had the second

cleaning of the year, it will be an out of pocket cost. These are not the only restrictions

that can be unnoticed in a dental plan but they are the most common things we have to

explain to our patients in the dental office. Knowing these aspects of your plan can

prevent painful financial moments during your time of dental need.

Customer Service Reputation

The name of some insurance carriers cause your dental staff to cringe when they see

you pull out that card. We know that we will not get clear or complete answers when we

check your benefits, and so we will probably be on the phone for 25 minutes repeating

your name, birth date and ID number a minimum of 5 fives as we are transferred from

person to person. We can’t get a good breakdown of benefits; therefore we can’t be

perfect on quoting your costs. We don’t like to shock patients with extra costs. We don’t

want to have that conversation any more than you do. There are various insurance

companies that provide the information quickly, completely and accurately. The

carriers that have the best online service typically are also easy to deal with on the

phone. So consider this. If I have 20 years ‘of experience dealing with dental insurance

and I cannot get the answers I need from your plan, how well will they assist you if you

need to call? I was once in a discussion with a patient considering two plans that were

very comparable and my answer to the patient when they called me was, “Both plans

pretty much function the same but XYZ company has better customer service in my

experience.”

Insurance is not getting less complex. Patients have more plans available to them and it

can be hard sometimes to know what options to choose. It’s important to know what

your plan does or does not cover before you pay the premium only to end up paying

again at the dentist.

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