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.