Insurance Hype and Dental Costs: Are You Covered?

Introduction

As a dentist, I strive to be a skilled surgeon. I also want to be a good businessperson who advocates for my patients by giving them as much value for their money as possible, while still making a fair living for myself and my family.

One way I can improve the outcome of dental care is by controlling all related costs, including setting my hourly fee (by far the largest cost for dental care) to be within the reach of regular people. I can achieve this without compromising quality of service or self-sacrifice. Another way I dramatically decrease my costs and pass those savings onto my patients is by purchasing quality materials in bulk. As the design and materials of a dental implant contain very little variation across many different manufacturers, it only makes sense for me to select the most affordable dental implants available with proven quality so I can reduce patient costs.

What does all this have to do with insurance?

Plenty. When they come to see me, most of my patients have dental insurance and sometimes their dental insurance will actually provide some coverage for the cost of dental implants. No plan covers 100% of dental costs incurred, although some plans cover 50%. The yearly allowable maximums of all real dental insurance (not reduced for plans) usually have co-pays that will pay up to $1,500 per year, and rarely more than $2,000 per year.

For many patients who do not shop around for affordable dental implant care, it quickly becomes apparent that this coverage is not enough. With the average costs of placing a dental implant spanning to the several thousand dollar range, even “good” dental insurance coverage barely contributes enough to make a dent. Dental insurance plans have maximums that are prohibitive in terms of implant treatment; it’s how the insurance company saves themselves money. Even with spreading treatment over a few years, which is a common way to help balance patient cost and dental insurance coverage, the final out-of-pocket costs are often still too astronomical to be within feasible reach for the average patient.

Besides the issue of low percentage of coverage, there are other issues with most dental insurance. Because of exclusions regarding treatment, sometimes there isn’t much coverage whatsoever. I charge low fees whether a patient has dental insurance or not. My fees are actually lower than the fee schedules that exist with insurance companies, making my treatment options the most affordable dental implant care by a wide margin.

What are the different types of insurance, and do they cover dental implants?

The benefit of indemnity insurance plans (they all pay money to the dentist) is that they give you some protection in terms of quality assurance. Pre-authorization by the dentist to the plans allows for an insurance company to determine if the treatment you are being offered is a plan benefit. Sometimes, but definitely not always, the insurance companies will say treatment is not appropriate. More often than not they will simply deny treatment and say its not covered, and will not tell you not to pursue it.

In other words, you get limited protection and are still largely on your own to decide if the care being offered is the best alternative, evidence proven, and at a reasonable cost. Indemnity insurance plans also allow you to complain about quality of work, and occasionally insurance companies will even post treatment x-rays, identify substandard work, and make the dentist give your money back. Finally, indemnity insurance plans—which include PPOs—allow you to make complaints and offer peer review committees to evaluate your complaint in your favor and get you your money back.

HMOs are a different story. They usually do not cover implants, and instead have a policy that if they do not cover implants dentists can charge whatever they want. Usually HMO insurance companies do not protect you with preauthorization quality control. In general, dentists do not like to preauthorize; they do not like to be told what to do. I encourage those without indemnity insurance to get second opinions. This is a personal form of preauthorization in treatment plans [or their need or cost don’t make sense.]

The final insurance plan available is that of the reduced fee for service type. Under this plan dentists agree to provide you free x-rays, exams, and some sort of cleaning at no charge. One of my acquaintances, who does a lot of business with these and HMO types of plans, figures it costs him at least $80 for the “free” visit. Because of this, he has to make sure, and always does, that he makes $80 or more with some other treatment plan. It’s the old bait-and-switch model where the dentist advertises low or no-fee services and then comes up with lots of treatment to be done, most of which is not a covered benefit of the patient’s insurance.

What other issues are there regarding insurance coverage?

Another related issue is that the insurance companies want their management fees. They let their participating dentists do pretty much whatever they want to patients as long as they don’t cause patients to complain. Peer review by HMOs is an art form. Offices are reserved for technical aspects of the office, but quality of care is rarely supervised in any manner. Indemnity insurance plans rarely if ever audit dental offices.

Conclusion

My ultimate message to you about obtaining affordable dental implant care with your dental insurance is this: Inform yourself about your coverage, and don’t avoid shopping for affordable dental implant care. Instead, inform yourself about practitioner track record, education, and fees in conjunction with carefully shopping around for dental insurance coverage. These steps will help to ensure that you find a great fit for you and your wallet.

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