The Tooth about Dental Insurance Part 3: Discount Plans

The final type of "insurance" is called a Discount plan. This type of plan is what you will typically find if you do not have a company that has a group dental plan. Personal dental insurance is very expensive and so many companies will try to sell you this type of plan at a reasonable price and say it is insurance.

The truth is, this is NOT insurance. Some dentists will sign up with these discount plans and all they have to is agree to charge those patients certain fees for each procedure. The problem is that most of the fees are VERY SIMILAR to a normal dentist's fees. They may be slightly lower cost depending on how high end that particular office is. But for the most part, its just a big waste of money. So make sure if you are getting insurance and its not from you work, that you are actually getting a PPO insurance, or at least (dare I say) HMO =/ . Otherwise you won't get any coverage and you will have spent your money on nothing.

The Tooth about Dental Insurance: Part 2 - HMOs

Here's a big one. HMOs, they make me sad and most people that have them don't understand why. Well I'm going to break it down for you right now.

HMOs(Health Maintanance organization) or DMOs(Dental Maintanance organization) are lower cost insurance plans that look very similar to buyer on paper but they are vastly different in operation. Many companies have an option for either and HMO or a PPO so choose PPO ALWAYS. Lets explain why.

I'm going to explain everything to you from the Dentist's perspective: so you will see what I see when I tell you that I don't take your insurance. First off, in order to get any benefit from your insurance you can ONLY go to a set let of dentists that the insurance company provides. This is different than a PPO because with a PPO you can go to any provider you want but there are certain places that you will save money if you go to because they have signed a contract with the insurance company.

Second, as we have established with PPO insurance you will pay a percent of a service for example: 20% of fillings and the insurance will pay 80%. So in the end the dentist will get 100% of the fee (not really but its close). The HMO does the opposite, the patient will pay a small % fee but the insurance will only pay 20% not the 80% to the dentist. This means that the dentist will only get about 40% of the fee. Since dentistry runs at about a 60-70% overhead, that basically means that for a filling, the dentist will do it at a slight loss.
And that is not just for fillings: MOST PROCEDURES WOULD END UP DONE AT A LOSS. So basically you have to ask yourself, how can a dentist keep his doors open if his insurance forces him to do things at a loss. I will bring a specific example: for the exam cleaning and xrays, the dentist gets 0 dollars from any one: insurance or patient. So what happens? They will delay you forever to get your cleaning... because they don't even get paid for it.

So what do they have to do? They have to find ways to charge you, the patient, to make a profit. Thats why whenever you do go to one of the offices that accept your HMO insurance, they will try and sell you extra products and services. Whether or not these services are necessary are controversial but basically thats why I tell patients that even though I do not take their insurance, they may still save money by coming to my office.

There you have it. I do not like HMOs they force dentists to make tough decisions and the one who ends up suffering is you, the patient.

The Tooth about Dental Insurance: Part 1 - PPOs

Lets take a moment to step away and talk about non-teeth here. Lets talk about something you worry about more: money.

Dental insurance is complicated and tricky. Even with my years of experience dealing with it, its still difficult to know the in's and out's because each insurance plan is unique even within the same company (or carrier)! A lot of what I'm going to say is somewhat hush hush in the dental community. No one wants to take time to explain it to the patient because its complicated and it only discourages people from what the doctor is more concerned with: your dental health!

Lets start off with the basics. There are 3 types of plans that you will most likely encounter:

A PPO (Preferred Provider Organization) or DPO(Dental Plan Organization) is your typical insurance that most people are familiar with. They have an annual Maximum benefit limit which is typically between 1000-2000 dollars. They also have an annual deductible that you have to pay whenever you need anything more than a cleaning and exam. This is typically between 50 and 100 dollars.

Usually these plans will pay a particular fraction of your dental bill depending on what services you need. They typically pay more for smaller things like fillings and less for big ticket items like crowns. The remaining portion of the bill is called you "copay". The bottom line is they are trying to encourage you to get your cleanings and exams and discourage you from getting anything else. These copays are specially designed to discourage you from using your insurance so they can keep money in their pocket.

With that said, this is still the best type of insurance you can have among the three choices.
Here's some other facts that will play into effect:

- Many insurance plans will not pay for composite or white fillings in the back of the mouth (where most cavities occur). Insurance plans were first developed when there was mostly silver fillings and have resisted the increase in prices of more expensive white fillings. They will pay you and the dentist less which will result and higher than expected copays

- Many insurance plans have waiting periods before you can obtain services. They sometimes restrict only the bigger procedures like crowns but others may even restrict smaller ones such as extractions or fillings

- Many plans have what is called a "missing tooth clause" which basically states that they will not pay for any prosthesis for a tooth that was already missing when you enrolled in the plan. This includes bridges, implants and dentures (partial or full)

- Most insurance plans do not cover braces for adults so get them while you're young enough to get coverage!

- When you have a PPO insurance you can use it to see any doctor you choose. However there are some differences between doctors:

1) Some doctors have signed a contract with the insurance company which means they have to charge the fees that the insurance company dictates and they have to be imbursed but the insurance company directly.

2) Some doctors do not have contracts and have higher fees that the insurance expecting. So even though the insuance covers say 80%, they only cover 80% of whatever their fee for the area is. This could lead to large discrepancies. so if you're dental bill is large even though you have insurance you may have a doctor in this catagory

3) Some doctors will not accept your insurance directly paying them. This does not mean you cannot get coverage with them though. They often will send the claim to the insurance company and the insurance will send you a check. However, the dentist will expect the full fee up front this way. As a dentist this is actually the most fair way to handle things because often times the insurance company has lots of little clauses to deny coverage for certain things and we often have to eat that loss or send bills that never get paid. However, most people will not accept this and I understand.