Let’s swish around the idea of dental insuRINSE, okay insurance, to be alphabetically correct. Is dental insurance really worth the cost you have to pay for it? Let me fill you in on a couple of interesting facts pertaining to dental insurance.
There are multiple carriers that offer dental insurance, Delta, Metropolitan Life, United Healthcare, etc. If a plan is offered by your employer, chances are you will pay less of a premium than if you were to get independent, individual coverage. Let’s address plans that are offered by your employer. Employers have options of plans they can choose to offer to their employees. This means that several different corporations could have the same insurance carrier, for example, Delta Dental. That does not mean however employees of all of these corporations have identical coverage. Just like you can pick and chose automotive insurance or home owners insurance, an employer can choose tiers of coverage. They can choose to get you the “gold” plan or “platinum” plan or whatever you want to call it which has better coverage or: they can choose to go with the bargain basement plan, which you find out is basically worthless when the time comes to use it.
Some plans force you to choose a dentist off a list rather than allowing you to choose your own dentist. These are usually the “bargain basement” type of plans (HMO’s and DMO’s) or the independent individual plans. The most common complaint I hear about these types of plans is that the patients did not like the dentist or the dental staff, felt like they did not receive good care, were rushed and felt they were duped into being “sold” a lot of dentistry they didn’t need. Could there be some truth to that? My opinion is yes!!! To provide good, quality care a dental office needs to charge a fair and reasonable fee.
When an office (dentist) participates with a dental insurance company, they concur to discount their fees according to the negotiated prices agreed upon. Since the HMO, DMO plans usually pay the least per procedure, the office that accepts that plan is forced to write off a considerable difference between the price they charge and the price the insurance company pays. Hmmmmmmm, could that be why those offices are so zealous in recommending a lot of dental treatment? Is it possible that they have to make up for the fact that they are not being compensated well by those particular types of dental plans? Do they create the projected need for more dentistry in order to offset the payment to charge and write off ratio? It certainly makes one ponder the thought, doesn’t it?
Now, back to the question of “Is dental insurance really worth the cost you have to pay for it?” Let’s throw in a few more interesting facts about dental insurance coverage: this holds true whether it is a plan offered by your employer or an independent, individual plan. More than ninety-five percent of insurance companies have what they term a “calendar year maximum allowance”. That means they will pay up to a maximum dollar amount over a twelve month period. The majority of plans range from as little as $750.00 up to a $2000.00 + calendar year maximum. The average dental plan has a $1000.00 calendar year maximum.
Now, that doesn’t mean if you have a bill from your dentist for $1000.00 the insurance company will cut a check for $1000.00. Oh no, that would be too simple. Different types of dental procedures are covered at different percentages. For instance, the least expensive type of procedures such as exams, x-rays, cleanings, etc. are typically covered at 100% of the fee charged. Fillings, some root canal procedures and other “basic” procedures are covered at a range from 60 to 80%. Finally, the most expensive procedures such as oral surgery, crowns, dentures, etc. are listed under major and covered at 40 to 50%.
The insurance carriers have also found a way to pay even less by using a clever tactic called “usual and customary” fees. For instance, let’s surmise that an office charges $1000.00 for a crown. Fifty percent of that would be $500.00, basic math, right? Well, the insurance company will convince you that your dentist is overcharging for the crown and that the “usual and customary” fee for a crown in that zip code is $700.00, so therefore they are only going to pay 50% of $700.00, in other words only $350.00. This leaves you covering the difference. Now I ask you if that calculation is routine, why do I have written estimates from different carriers for the same procedure code with different “usual and customary” fees? Shouldn’t they all be the same if they are entering a zip code as their base to determine the fee charged in that zip code? Again, makes you wonder, doesn’t it?
In addition to limiting the amount of funds they will pay out within a twelve month (calendar year) period, basic and major procedures (the ones covered at lower percentages) will also be subjected to a “deductible”. This ranges from $25.00 to $100.00. So, in closing let me throw in one more mathematical equation. If you pay $50.00 a month to have dental insurance ($50.00 x 12 = $600.00 yearly), and the insurance carrier has a $1000.00 calendar year maximum allowance, what is the dollar amount of benefits you are truly receiving? That’s right, a whopping $400.00!!!!
So, you tell me, “Is dental insurance really worth the cost you have to pay for it?”
Paul L. Caputo, DDS3490 E Lake Rd S Suite A