Your Dental Benefits: The Inside Scoop About How Your Dental “Insurance” Really Works

Are You Confused About Your Dental Insurance Policy?

Insurance questions are some of the most frequently asked questions at our dental office. The truth is, we are often just as confused about insurance coverage as you are. Here’s what we do know:

Dental insurance policies are really not insurance policies at all; they are a benefits package – and they work very differently from medical insurance policies. For example, Insurance policies have a maximum amount paid to the policyholder – which can be as high as $2 million or more over the lifetime of the policy. Most people will never use anywhere close to their maximum dollar amount over their lifetime. In contrast, a dental benefit plan may only allow a maximum benefit of $1,200- $2,000 per year – and that maximum amount could be used up with a single dental procedure such as a crown, root canal or implant treatment.

Keep in mind: Insurance companies are for-profit companies and like all for-profit companies, they have one business goal: To make money. How do they do this? They must collect more money (from selling their insurance policies) than they give out (in claims) to the people they insure.

Depending on your dental insurance plan, you are allowed partial coverage for certain specific dental procedures as listed on the plan. Not all plans pay for all necessary dental procedures. If your plan does not provide a benefit for a procedure you may need, you will receive no money from your dental “insurance” company. It’s all very confusing because the amount the insurance company will pay for each dental procedure is different depending on the specific policy and depending on the dental procedure performed — and in the end, the insurance company reserves the right to deny a claim for any number of reasons that are explained in the small print on the policy. Here’s an example of the small print from one insurance company which is typical for most policies:

“These are general plan benefits; any payments, implied or otherwise, are subject to all policy provisions and limitations in force at the time services are rendered. This Statement is not a guarantee of eligibility and/or benefits. Waiting periods (for coverage) may apply.”

We thought about making the print even smaller, but you get the point.

What we find in our office is that quite often most patients have never read their dental benefits policy and/or have no understanding of their coverage.

Patients will ask us if we accept their insurance. The simple answer is, yes. But, we truly do not know if your insurance company will pay for your treatment or not! Most dental offices, including ours, contract with a few insurance agencies, but just because we do or do not contract with an insurance company does not mean they will or will not honor your claim. There are hundreds of insurance companies and multiple plans within each company. As dentists, we aren’t in the insurance business – and the policies are constantly changing – so it’s virtually impossible for us to know what every plan covers. When we answer, “Yes, we accept your insurance,” what we are saying is: Yes, as a convenience and a courtesy to you, we will submit a claim on your behalf, stating what treatment has been received at our office and what the cost of that treatment is. We can make an educated guess about how much your policy might pay for a particular treatment based on past experience with your insurance company, but we can never predict how much your insurance company will pay for that procedure with 100% accuracy.

It is ultimately the patient’s responsibility to understand their policy coverage and to pay the balance on their account once their insurance benefits have been received and applied to the account.

In our experience, patients hand us their insurance card (with no knowledge of what their coverage is) and they assume their insurance will cover their costs. When the insurance company denies full (or any) coverage, patients come back to our office upset that they owe more money. Often, we are “accused” of changing our fees – which is not true. Our fees for specific dental treatments are always explained to patients prior to treatment and the patient signs an agreement for treatment and payment in full prior to the procedure. We don’t change our fees – the insurance companies change what they agree to pay for those services because of the small print mentioned above – they “reserve the right to deny claims” for any number of reasons. But the insurance company is an “invisible” entity so typically the dental office becomes the bad guy and patients are upset with us because they end up owing more for their treatment then they expected because their insurance did not pay what they expected it to pay.

Unfortunately, when a patient has a dispute about coverage with their insurance agency, our small business is left waiting for the dispute to be settled and to receive payment from either the patient or the insurance company. Meanwhile, we have dental supplies to purchase, utility bills to pay, and staff who rely on their paychecks.

How do we work together to solve this insurance coverage problem?

  • Please come into our office knowing that we have your best interest in mind and our goal is to treat you as an individual and to provide you with the highest quality dental treatment.
  • Our office mission statement is: “To provide the highest quality dental care while exceeding the expectations of our patients.”
  • We are proud of the quality of dental care we provide to our patients. We make no excuses for the fees we charge; quality care costs money. We have technically advanced dental equipment, we use only the highest quality dental materials, and we use reputable dental labs.
  • We will always be honest and upfront with you about your treatment plan and the fees associated with each specific plan. It is never our intention to mislead any patients about costs.
  • Please be informed of your individual dental benefit plan prior to signing our treatment agreement. Please be prepared to pay your account balance once your insurance benefits have been received and applied to your account.
  • We want your experience at our office to be positive. We understand that you may be fearful or anxious about your treatment. You should not have to be anxious about paying for the dental treatment you need.

Your Final Takeaway

Please know that any reputable dentist is not trying to find dental work to be done in your mouth to get money from insurance companies. Most of us would rather never have to deal with insurance companies – EVER! We would much rather spend our time providing quality dental care and educating our patients about their dental health. Often, we find ourselves spending valuable patient time trying to explain dental health benefit plans – to the best of our ability – remember; we’re not insurance experts- we’re science majors! Please do your dentist a favor before your next appointment; know your dental insurance plan – know which treatments are covered on your plan–and be aware that that coverage can change without your insurance company notifying you – it’s not the dentist’s fault.

And don’t forget to Smile – Your dentist really does want to make the world a more beautiful place – one smile at a time. He/she doesn’t like to be the constant butt of dental jokes – if he did, he would have gone to school to be a proctologist.