Most patients have a hard time understanding their dental benefits. There are as many different plans as there are contracts, and dental insurance is not the same as medical insurance. In fact, it’s not really “insurance” at all.
A patient’s employer selects the plan and is ultimately responsible for the design of the contract. Each contract specifies what procedures are covered. Even if a procedure is dentally necessary, it may not be covered. This doesn’t mean it isn’t needed, of course, it simply means it’s not “covered.”
Patients might believe that a non-covered procedure is not necessary, and the dental office team must be ready to explain why it is. Patients should be told, gently and appropriately, that coverage is not the sole consideration for accepting recommended treatment.
Here are some frequently asked questions heard in dental offices. Here I’ll attempt to answer them well.
• “Why doesn’t my insurance cover all the costs of my dental treatment?”
Dental insurance isn’t really insurance at all. It is not a payment to cover a loss. It is actually a benefit provided by employers to help employees cover the cost of routine dental treatment. An employer will buy a plan (one of many offered) based on the amount of the benefit and the cost of the premium for the company or the employee. Most plans cover only a part of the total fee for dental services.
• “Why aren’t my exams and cleaning, among other procedures, 100% covered like my plan says?”
The insurance company typically allows 100% as payment for the procedure. It isn’t always what the dentist may charge. An insurance company may allow $60 as payment for an exam, but the office fee is $80. This leaves $20 that the patient is responsible for.
• “Where do the allowed payments come from?”
Most insurance companies call these payments “UCR,” which stands for usual, customary, and reasonable. But these don’t mean what they sound like. They are actually a list of payments negotiated by the employer and insurance company. The amounts are related to the cost of the premium. In other words, the lower the allowed amount, the lower the premium paid by the employer, or whoever is providing the plan.
• “What good is my insurance if I always have a balance?”
Even if the fee is not fully “covered,” at least it pays part of it. This should be stressed to the patient. Any amount reduces the out-of-pocket expense for the patient. Something is better than nothing!
• “Is the dentist charging more than he/she is supposed to?”
This question is usually in response to a patient receiving an EOB (explanation of benefits) from the insurance company. Remember that the amount paid for treatment is the negotiated fee between the insurance carrier and the employer or provider. That amount is applied to the actual fee. Typically, this negotiated fee is much lower than what dentists in your area are charging. It does not mean the dentist is overcharging.
• “Why did my insurance company change the treatment to something less expensive?”
Again, this question typically follows a patient receiving an EOB, and the answer is very similar to the previous one. The benefits are negotiated and many times will provide only for less expensive procedures.
Obviously, if a tooth needs a crown, but a filling is all that’s covered, it does not mean that the dentist should do a filling. At least some benefit is paid, and that will be applied to the fee for the recommended treatment. It is the responsibility of the dentist to provide the best treatment. It is the insurance company’s responsibility to save (make) money.
• “Why doesn’t my dentist participate in my network?”
Many dentists are uncomfortable with the restrictions that are placed on them by “network” plans. I didn’t participate in any of them in my private practice because it affected my relationship with patients. In other words, my patients were trusting me to be their doctor—not the insurance company—and I wanted patients and I to make the best decisions for their dental health.
• “Can I do anything if my insurance doesn’t cover the treatment I need?”
The coverage is between the patient, the employer or provider, and the insurance carrier. The dentist has no power to make the carrier pay for recommended treatment. There can be some intervention on the part of the dentist, but it is limited at best. The patient simply must be responsible for the total cost of treatment. Patients might be able to file complaints with the state insurance board or commission if there is a legitimate reason.
I recommend that my clients take these (and other questions from patients regarding insurance) and develop “scripted” answers based on the information provided here. Being prepared will help tremendously when you’re dealing with patients who had other expectations from their insurance. Remember, dental “insurance” is very different that medical coverage. You and your team should be prepared to explain this to your patients.
The bottom line is this—you, the doctor, need to recommend and deliver treatment based on your best diagnosis and prognosis, and then educate patients based on that. Please don’t ever let a third party, someone who has very little interest in the health of your patients, influence or dictate what you know is best for your patients’ dental health.