Is Dental Insurance Your Friend or Your Foe?

To the question of whether dental insurance is a friend or a foe, from my perspective, it is a little of both. We are pleased if a patient has dental insurance to offset the cost of their dental treatment. But, there are some truths and myths about insurance that we felt you should know about. Insurance is like that double edged sword that can work for you, or if you are not careful, it can cut you, too. We hope that this blog article clears up some of the misconceptions about dental insurance.

Our goal is to provide you with extraordinary service, to help you achieve the level of wellness that you desire, and to maximize your insurance benefits. We are happy to be your advocate to the insurance company and to make sure that you receive every penny that you are entitled to. But, we felt that it was important to inform of situations when your friendly insurance company is ... not so friendly.

Myth: The Insurance companies pay a fair benefit: One myth espoused by the insurance companies is the Usual Customary Reasonable called the UCR. The UCR is supposedly the fair amount that a dentist should charge for a given procedure. If the UCR is valid then every insurance company would have the same fee for the same procedure in any given zip code. But, that is not the case. We see the UCR fluctuate wildly.  

A patient came into my office with 100 percent coverage on everything. This was absolutely unheard of. The kicker was that his insurance company’s UCR was less than 50 percent of the average dental fee, so the patient paid over 50 percent of each procedure anyway. The UCR is specific not only to an insurance company, but also to a specific policy within that company. The truth is that the UCR is directly proportional to the amount of premium that is paid by the policy holder. 

Myth: the insurance company has to protect itself and you from the rising costs of dentistry: Both employers and insurance companies often complain about the rising cost of dentistry. But, let’s look at the facts. When dental insurance was first introduced in the 1960s the average yearly maximum was $1000. Now, over 30 years later, the median yearly maximum is still $1000. Indexed to inflation the yearly maximum should be over $8000. To put it another way, that $1000 of insurance in 1960 is only worth $125 in today’s money. So, your dental insurance would pay for eight times more dentistry in 1960 than it does now. But, did your premiums decrease or even stay level? 

Myth: Insurance companies will pay for the appropriate dental treatment: The insurance contracts are often written with alternate benefit clauses. These clauses allow the insurance company to substitute and pay for a lesser service than the one that the dentist provided. For instance, many insurance companies will not pay for a patient’s bridge if there are more than four teeth missing in that arch. Often an insurance company will substitute the least expensive and often inferior treatment rather than pay for what is in the patient’s best interest.

On more than one occasion I had patients with a cracked tooth. Every time that they bit down or chewed they were in severe pain. The best and probably only effective treatment for cracked tooth syndrome is to crown the tooth - to bind the tooth so the crack doesn’t flex and spread. The benefits for the crown were denied because the tooth hadn’t fractured, yet. Even though the patient was in pain every time they bit down. The new crown remedied the procedure, but the insurance company never paid a nickel because it hadn’t broken, yet.

The patient is at the mercy of the insurance company’s contractural arrangements. We feel that it is unfortunate when your insurance company stands in the way of you receiving the treatment that you desperately need. We are glad that you have the insurance as to help defer the costs of your dental treatment. 

It is unfortunate, but insurance companies just do not pay to make people well.  It is then up to the patient to pay the difference between the minimal level of care supported by  the insurance company and the actually cost of wellness. It all depends on how well you want to be.