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Elizabeth Duling, DMD - Owens Cross Roads & Hampton Cove Dentistry

Why Does My Dental Insurance Pay So Little? A Real Eye Opener

April 4, 2019

You’ve just seen the dentist for the first time in a couple of years. You are not surprised to find out that you need a couple of fillings and a crown. “No big deal,” you think to yourself, “after all, I have dental insurance.”

 

However, you find out that your dental insurance doesn’t cover nearly as much of your treatment plan as you thought it would. In fact,  you’re left paying for most of it out of pocket.  Why is this happening if I have insurance!  It is simple really, but also very disappointing.  Dental insurance is not designed for your individual needs. It is designed, based on an equation, to make the insurance company the most money possible.

 

Is Dental Insurance Just a Big Rip-Off? 

Having dental insurance is okay if the amount you pay the company is less than the benefits that you receive. Paying for a policy each month is enough to cover all of your preventive services (checkups and cleanings) and maybe a little more. So, if you need a filling or two, you can schedule the procedure without having to worry about going over your maximum allowable benefits for the year. A maximum allowable is a set dollar amount that your insurance will pay up to, but not over.

Keep in mind, you also have a deductible or co-pay that you need to pay before your insurance will pay for any dental treatment (this is to discourage you from getting treatment). There’s a fine balance of math that needs to be done. For some people, having dental insurance can help them budget better and save a few hundred dollars a year, or at least get a discount on a filling every now and then. For others, it winds up costing more to have insurance because it doesn’t cover what they need it to or covers things that they will never need.

 

Two basic cleanings ($90-150 each), 2 established patient exams (about $50-75) and 1 set of cavity checking x-rays per year ($50-90).  If you do not have any other needs you will likely pay $330-540 per year.

 

How to Know Which Dental Treatments Are (or Are Not) Covered by Insurance 

As a general rule, your dental treatments are categorized into a few different types of services, each under a different tier of coverage. Preventive services, like cleanings or exams, are typically covered at 100%.  There are some plans that do not pay for anything else.   When you go past preventive treatment then your insurance stops paying as much.

 

Basic or minor treatments like small fillings are partially covered (usually around 75-80%) but only after you’ve paid your deductible and any co-pays. However, if you have too many basic treatments that need to be completed, you may be at risk of going over your maximum allowable amount before everything is done.

 

Now let’s say you need major work, like a crown. The coverage on your dental policy drops even more, down to around 50%. If you need more than one tooth worked on, there’s a good chance that the additional teeth aren’t going to be covered, because you already maxed out on your benefits.

Finally, elective services such as dental veneers, teeth whitening, etc. are not ever covered by dental insurance. They’re considered cosmetic, so they aren’t medically necessary. 

 

Other reasons insurance companies with refuse to pay are:

Waiting periods

Missing tooth clauses

Deciding to pay for a lesser service (think silver vs amalgam fillings)

Changing their minds after issuing a preauthorization

Losing or ignoring information included with the claim.

 

“I Thought Dental Insurance Was Supposed to Cover Everything I Needed”

Depending on how you look at it, dental insurance does help cover everything that you need…but only if your needs aren’t very big. It’s when problems get put off for a while or are very complex that most people find themselves having to pay out-of-pocket for a majority of their dental treatment.

 

Prevention is the best medicine…especially when it comes to your teeth. Regular cleanings, exams and x-rays are necessary to find problems when they are small.  Following treatment recommendations early can save you time, pain and money.

 

Can’t My Dentist Write-Off My Out of Pocket Expenses?

 

Your dentist could lose their license and even be jailed for doing what seems like a favor to a patient.  It is insurance fraud.  Why? Insurance companies require a dentist to give them a copy of all of the fees that they would charge a patient without insurance and to agree to only charge their patients a reduced fee as part of a contract.  To not collect accordingly is a breach of contract. From the insurance company perspective it makes sense.   Not collecting copays or patient portions encourage patients to seek treatment and use more benefits.  Again, they want to make the most money possible- pay out as little as possible of what they have collected.  Insurance companies perform audits to make sure dentists are not writing-off too much.

 

Are there any other options?

 

Some dental offices now offer their own discount plans.  The plans have no maximum spending limit, no pre-authorization requirements, no waiting periods, no waiting periods and no risk of denied services.  These plans only work in the dental office that you have chosen.  The plan allows the office to save the time and headache of dealing with large dental insurance companies.  Let’s face it, dental insurance companies are in the business of making money.  Your dentist is in the business of fixing teeth.

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