Dental Insurance 101 ---A patient primer

Posted by Dr. Edward Magida | Filed under , ,

I am writing this article as a last ditched effort for people to try and understand just what it means to have and use dental insurance benefits. Please be aware that dental benefits have not changed much for decades, meaning that the amount an insurance company will pay is still the same it was 25 years ago, even though the cost of dental treatment has gone up like everything else.

I am going to list a bunch of things people have done or tried to do with their insurance as told to me by people in the dental profession. Sometimes things were done out of being ignorant of things. Other times things were done out of frustration. Hopefully, by reading about this topic you can get a handle on just what dental benefits you do have….or don’t have!

Here are things patients have done, or tried to do

  1. Not paid their co-pay for a procedure.- Very few procedures are paid in full by the insurance company.
  2. Not paid their deductible.- This is a once a year payment that is due to the dental office.
  3. Not paid because their insurance “maxed out”.- If you need a lot of treatment, and you use up your benefits, you still are obligated to pay your balance for the treatment you needed and authorized your dentist to do.
  4. Not pay for a procedure if the insurance company “downcodes” a procedure, and therefore pays at a lesser amount.-Insurance companies are not known for always paying for better quality materials used in many dental offices today. They will pay for what they consider “adequate materials”. Do you want your mouth to be “just adequate”?
  5. Play ignorant about their policy benefits.- If you do not understand just what is covered, call the company and ask them. It’s your plan.
  6. Play ignorant about their yearly maximum benefits.-At some point, if you have much treatment, your policy will max out and you will owe the entire treatment bill yourself.
  7. Get upset because “their dental office doesn’t keep track of all aspects of their policy”.- There are hundreds of policies out there. It is not possible to expect your dental office to know everything about all the policies.
  8. Get upset with their dental office because insurance is messed up, when in reality, the patient gave the wrong policy information to the office.-Make sure we have your correct birthday, social security number, insurance company address.
  9. As the office to falsify dates of service in order to collect benefits.-I’m not losing my license for anybody!
  10. Get upset when their dental office doesn’t keep absolute track of a person’s remaining benefits.-It’s much easier for you to keep track of your remaining benefits, than for your dental office to keep track of the benefits for several thousand patients.
  11. Get upset when their dental office does not know to the absolute penny, how much of a benefit is to be expected.-Many times we do not know exactly how much will be paid until the check arrives.

C’mon folks. Get real. Whose benefits are these anyway? They are not the dentist’s. The dentist is just trying to do what’s best for the patient. You the patient absolutely need to understand your own benefits. You need to know what procedures get reimbursed at what percentages. You need to know that certain procedures, although deemed necessary by your dentist, might not be covered. It is not the dental office’s fault if your coverage is lacking!

Dental insurance should be looked at as a possible bonus towards treatment you need. It should not be looked at as the reason to get or not get treatment.

If you have dental benefits, that’s great. It will definitely help with paying for your dental treatment. All I’m asking is for you to be part of the picture. It’s your plan and you should know what it does or does not do for you.

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