Did you know that each year insurance companies make millions of dollars off patients who forego necessary and preventive dental care? Many individuals who are paying for dental insurance do not realize that their plans provide coverage up to a certain dollar amount annually. Consequently, some patients are not scheduling the dental treatment they need, deserve, and have insurance to cover. Thus, the insurance revenues allocated to pay dental claims on many patients are never used, and, unfortunately, those dollars cannot be carried over year-to-year. The bottom line: what the patient does not use they lose. Clearly, it pays in many ways to schedule the preventive care or other dental treatment that you need. We are here to help you secure the insurance coverage available to you on every dental procedure you schedule.

Understanding Insurance

The first thing to understand about dental insurance is that it isn't insurance at all. Insurance originated as, and is by definition, a pooling of funds to pay for a rare but catastrophic event. Fire insurance is an exellent example. Originally, medical insurance was also designed this way. Payment for routine office visits, basic medications, and low deductibles are a relatively recent modification in medical policies to create additional employee benefits that are not true insurance but "tax free" benefits.

Restrictions and Limitations

      Unlike events like cancer or your house burning down, dental disease is neither rare nor catastrophic. Therefore, dental insurance isn't insurance at all but really a method for employees to receive "tax free benefits". Rather than insurance, it is more accurate to refer to them as dental benefit plans. When originally introduced in the 1970's, these plans were very simply designed and employees could go to any dentist. To keep premiums reasonable, total benefits in any one year were limited to $1000.00. Thirty years later, most benefit plans still have this same maximum limit. Premiums, of course, have gone up because the costs for administering these plans (employee wages, cost of living, etc.) have increased. To help  attempt to keep premium costs down for employers and to continue to serve shareholders with profits, healthcare companies have significantly modified the original plan structures. This is the reason there are a variety of plans available such as dental capitation plans, dental HMO's, dental preferred provider organizations (PPO's), dental referral organizations (DFO's), etc. It is just as hard for dental offices to understand the details of all these different plans as it is for the patients! The bottom line however in all these alphabet soup plans, is RESTRICTONS and LIMITATIONS. The most common restriction is whom you are encouraged to choose for your dentist. Actually, it's against the law in most states to restrict you from seeing any healthcare provider you want but, should you go out of the "network", your benefit may be reduced by 10-30 percent. In all of the restrictive plans, there is not only a contract between your employer and the insurance company; the plan dentist has signed a contract as well. The benefit for the dentist is that his/her name appears on a list and you are encouraged to choose this practitioner. What the dentist has to agree to in order to gain this "preferred provider status" varies from contract to contract.

       Limitations can take many forms. The most common is to exclude certain services altogether, usually the better treatments or the newer, superior services now available because of advancements in science and technology. Another limitation is the "LEAT" clause, which stands for Least Expensive Alternative Treatment. Essentially, this clause allows the insurance to choose to pay for a lesser benefit for the cheapest material or treatment that they consider is adequate for you. This is a very broad power and it is a clerical person sitting at a computer that usually makes this determination. Even when referred to a dental consultant, the judgement is still made by a company employee who has not even seen the condition being treated.

        What all this means is that the changes in dental benifit plans over the last decade have changed the benefits to you, the employee. Whereas benefits were once determined based on need, they are no longer based on need, but on specific contract terms negotiated between an employer and a healthcare insurance company. In plans that direct you to specific dentists, there is also a contract containing specific agreements between the insurance company and the dentist.

Summary

      The common theme today when dental benefit plans deny or reduce benefits is to imply that the care is not needed or that the fee charged was too high. We feel you are the best judge of your need, not a clerical person at an insurance company. Our response to the insurance company is that their benefits are too low. Once again you are the best judge whether our fees match our quality.  Whatever dental coverage you may have, we are here to help you get the most out of your plan. If you have questions relating to your dental benefits, contact our office at (205) 921-0893 and we'll gladly assist you in getting the dental care you want and deserve. Remember, what you don't use, you lose!