Ask a Dentist:  Why Doesn’t My Dental Insurance Pay for Everything?

If there is one thing that frustrates me the most as a dentist, it is dental insurance.  There is such a misconception about this topic that I felt compelled to write about it in the hopes of educating the general public.  Most people believe that dental insurance and medical insurance work the same way.  In short, they don’t.

We are accustomed to a small copay payment each time we visit our physician’s office or anytime we get a test or procedure done.  Medical insurance usually covers the majority of a patient’s medical expenses.  Dental insurance does not.  Since the 1970’s, insurance companies have paid annual maximums of around $1,000 – $1,500 per person for any needed dental treatment.  We are now in the year 2019, and insurances STILL pay annual maximums of $1,000- $1,500 per person.  If the insurance companies had kept up with the increased cost of supplies, employee wages, liability insurance, lab bills, continuing education, inflation, and the other numerous expenses dentists accrue for the privilege of providing quality care to their patients, then annual maximum payouts would be SIGNIFICANTLY higher.  Dental insurance is a business, and these companies are not in it for charity or for the best interests of the patients on their plans.  They are in it to make a profit…collect premiums and pay out as little as possible, period.

The best comparison I have heard about dental insurance is to think of it like a “discount coupon” or a “maintenance plan”.  If a patient has generally good oral health and only needs their two healthy patient cleanings and a few fillings now and then, it can be a good value.  However, if there is one major dental problem during a calendar year,  or if there is ongoing treatment of gum (periodontal) disease requiring more than the usual two visits per year, that insurance plan will likely max out after that one big procedure or after only two of the four necessary periodontal visits.  Insurance will help with about 50% to 80% of the cost of a major treatment, up to the calendar year maximum, and then they are done.  The patient is responsible for the remainder of the fees involved with their treatment.  So when I hear a patient say, “I only want to do what my insurance pays for”, I have to tell them that insurance doesn’t pay for much.  If a patient only wants what insurance pays for, then they are looking at doing the barest minimum of oral health care.

Doing harm to the doctor-patient relationship is probably the biggest problem inflicted on us by dental insurance companies and their representatives.  Many colleagues and I have had countless patients receive false and sometimes outright deceitful information from their insurance companies. These false statements are geared to placing the blame on the dental office as somehow doing something wrong, and for the purpose of delaying payment.  These falsehoods have included telling patients that a claim was never filed, x-rays were not sent, the wrong procedure code was used, the treatment that was done has a poor probability of success and is therefore denied ….and the list goes on and on.  I know how diligent my team is about filing things correctly, and even providing more information than required in order to minimize our patients’ out-of-pocket expenses.  Also, it is illegal for a third-party insurance company to dictate treatment for any patient.  Insurance company personnel have never examined the patients, so how in the world would they be able to diagnose or decide on the best treatment for an individual person who is under the care of a licensed dentist?

Putting ridiculous rules into play that limit our ability to do what is in our patients’ best interest should be illegal, but unfortunately it is the norm.  Among the rules insurance companies often use to either delay or deny paying full claims are as follows:

1.One-year waiting periods for major dental work (such as crowns)

2.Frequency limitations (such as a 5-10 year wait before paying for an existing crown to be replaced, even in the presence of breakage or decay)

3.Bundling and down-coding procedures (such as paying for a cheaper amalgam filling instead of a tooth-colored resin filling, or combining a core build-up and crown into one universal fee even though they are two separate procedures)

4.Refusing to pay for bitewing x-rays and panoramic x-rays on the same visit (when the first are used to check for cavities between teeth and the second can help detect oral cancer)

5.“Missing tooth clauses” to avoid paying to replace a tooth that was already happened to be missing prior to the patient entering into the insurance contract

6.Stating that a procedure will be covered on a pre-estimate, only to deny it after the procedure is completed

7.Denying payment for treatment done by out-of-network dentists, and forcing patients to choose from a list of “preferred providers”

Many patients are confused by the terms “out-of-network” vs. “in-network” (the same as “preferred provider”).  When a dentist signs up to be in-network with a dental insurance carrier, that dentist is agreeing to abide by the insurance’s set procedure fees, which are sometimes lower, as much as, 40-50% than the normal fees in their office.  The dentist is also under obligation to abide by the insurance company’s rules and limitations as mentioned above.  It is NOT because the insurance company selected those dentists for some level of superiority to other dentists.  So why in the world would any dentist sign up to be an in-network “preferred provider”?  Many of us, especially in our early years of practice, need a way to attract new patients to our offices while we are the new dentist in the area.  Going in-network with insurance companies automatically puts us on a list that goes to every patient on that plan.  If a dentist is in-network with one of the major dental plans that has thousands of patients in their geographic area, they have a major pool of new patients who are likely to seek out their office for dental care.  In essence, it is a marketing strategy.  We sacrifice and greatly discount our fees as a pay-off for receiving more patients.  As our practices mature, we get busier, and we develop great relationships with our patients, the need for being in-network begins to diminish, as our patients begin to refer friends and family to us.  Also, as time goes on and we know that our experience and expertise allows us to provide a higher level of quality care, we get weary of having to fight with insurance companies to pay their fraction of the payment for patient care, and weary of trying to explain to patients how their insurance plans work.

Because there are literally thousands of different dental insurance plans, even within the same company, it is impossible to accurately predict exactly how much a given plan will pay for each procedure.   My team does their absolute best to get the answers and estimates prior to the patient scheduling for treatment, but since the insurance companies won’t guarantee their estimates, neither can we guarantee their estimates.  Patients end up frustrated because they don’t understand why dental insurance won’t pay for their needed treatment, and we end up frustrated because we feel like we are losing the trust and confidence of our valued patients.

I speak for myself, but also for so many of my fellow dentists, when I advise all patients with dental insurance to please speak to their human resources person or their insurance company to try and understand what they are really signing up for.  People may be paying a higher amount for their insurance premiums than they will be receiving back in payment for their needed dental treatment.  And please don’t shoot the messenger…we will fight for you, but even the toughest warriors grow tired and lose battles sometimes.

Credit goes to one of our colleagues Dr. Lester for writing this article.