I am writing this blog post for one primary purpose: to help my patients understand how their insurance works, so there are fewer of those awkward financial conversations in dental offices everywhere.
Let’s first get one thing out of the way before we discuss the nuances of insurance. One thing I want everyone to know is that dental insurance is THE PATIENT’S insurance. It is not the dentist’s, or the dental office’s. When you signed up for that dental insurance plan, you made the agreement that you are responsible for what the insurance does or doesn’t pay, what the coverage limits are, and all the fine print that goes with it. A dental office will verify your insurance, provide you with an estimate, and file the claim as a courtesy, but they are not obligated to do so. You are responsible for all the charges of that appointment and if insurance doesn’t pay then it will ultimately become your financial obligation.
Next, let’s also realize that insurance is in the business of making money rather than writing checks. If they can find a way out of paying, you’d better believe they will. They have highly trained and motivated individuals that will find the loopholes in the fine print of your plan and use it to refuse to pay. We’ll talk about those loopholes in a bit.
Two Main Types of Dental Insurance
There are two main types of dental insurances: 1) PPO and 2) DHMO. There are other forms of dental insurance such as CHIP, Medicaid, and discount plans, but I won’t get into those. I will defer the conversation about DHMO’s to another blog post because they are a horrible form of insurance and I will briefly explain why.
PPO stands for Preferred Provider Organization. If you have a PPO dental insurance, you have the luxury of going to whichever dentist you please. Most dental offices will accept your insurance, but some may not be “in network” with them. It is important to distinguish “in network” vs “out of network”. An office that accepts your insurance and is “in network” with the company will file a claim to your insurance on your behalf, and have an agreement with your insurance company in regards to the price of the procedures. If an office accepts your insurance but is “out of network”, then you will still be able to be seen at that office and your insurance may still cover a portion of the appointment, but the office is allowed use higher set of pricing due to them not being contracted with the insurance company.
Let’s use an example to illustrate this point. Let’s say you’re at your annual exam, and you’re told you need a crown. The office price for a crown is $1,200. If the office is “in network”, then they have an agreement with your insurance company that the fees will be set to a certain price for each procedure. These fees are typically lower than an “out of network” price. Even though the office price is $1,200, the insurance fee may be as low as $750, which can end up saving the patient money on the procedure. If the office is “out of network”, the office is not held to a contracted price and the fee will remain $1,200.
It is important to remember that when dealing with “in network” insurance, the pricing is coming from the insurance company and not the dental office. The dental office entered into a contract with your insurance company to honor those prices, and charging anything other than the contracted pricing is considered insurance fraud.
A great thing about PPO insurance is that you can go to whatever dentist you want. This means that if you have a dentist you love to go to, you can see them even if they are not in network. This differs from a DHMO insurance, where you don’t have the choice of where to go to.
DHMO stands for Dental Health Maintenance Organization. These plans tend to be more inexpensive compared to a PPO. Very few private practicing dentists are involved with these due to their low level of reimbursement. When you sign up for a DHMO insurance, you are assigned to a specific dentist and/or office. Going to a dentist that you are not assigned to will result in the insurance company not paying for your visits, leaving the patient stuck with the full cost of treatment.
How Insurance Companies Get Out of Paying
So back to the loopholes. What are they? The first major loophole is a “downgrade”. This basically means that while the patient and the dentist agree on a more aesthetic procedure, the insurance will only agree to pay for the standard procedure. For example, very few dentists do silver fillings these days and opt for composite/tooth colored fillings. While composite/tooth colored fillings are more aesthetically pleasing, they are also more expensive for the dentist and the insurance company. Instead of the insurance company paying at the composite/tooth colored filling price, they will pay at the silver filling price and the patient will be responsible for the difference. The other most common downgrade is your insurance company paying for a metal/silver crown on molars/back teeth, rather than a porcelain/tooth colored crown.
Other loopholes that exist in dentistry are frequency of procedures. Almost all insurances cover exams, x-rays, and normal cleanings at 100%. Most insurances allow two per calendar year/benefit period, while some insurance plans will allow 1 every 6 months. If you schedule your next cleaning before your insurance frequency allows, it then becomes your financial responsibility. Frequency of x-rays, replacing old fillings and crowns, and classifying certain procedures as cosmetic rather than medically necessary are other commonly encountered loopholes.
Use It or Lose It
Your dental insurance is for your benefit, but the insurances companies aren’t necessarily excited to write checks for you. At North Austin Dentistry, we are proud to say that we are in network with most PPO insurances so that you can use your benefits. You worked hard for them, so use them! Examples of PPO insurances that we accept are Delta Dental, Cigna, United Health Care, United Concordia, Humana, Guardian, Blue Cross Blue Shield, Dental Select and MetLife, as well as many others. We have an excellent staff that is willing to fight to maximize your insurance benefits.
If you would like to maximize your benefits, give a call and we’ll get you scheduled. Remember that with insurance benefits, if you don’t use it, you lose it!