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