What the Heck Is Up With Dental Insurance Benefits?

What the Heck Is Up With Dental Insurance Benefits?

Does this sound familiar? You go to the dentist for your routine dental visit, as is right and good. But during your exam, your dentist said that you need to have a dental crown placed and as it turns out, your dental insurance carrier will not cover the full cost.

Or maybe you’ve experienced being seen for a dental cleaning only to receive a bill later. Your insurance said that dental cleanings are covered 100 percent, but then you still owed a small amount! What’s going on?

Dr. [doctor_name] and our team know that dental insurance can be both confusing and frustrating at times, so we’re here to answer your questions. We’d love to help you better understand what you can expect from your dental insurance provider and it all starts with learning more about dental insurance.

A Brief History of Dental Insurance

In the mid 1960s to early 1970s, dental insurance was born. It was Delta Dental who first offered dental insurance with a maximum of $1,000. And that covered a decent amount of dental care in the 70’s. Heck, $1,000 could get you a lot of things during that time.

Let’s fast forward to today.

Almost 50 years later guess how much the insurance maximums (on average) are?

$1,000. Yes, you read that right. They are still the same.

If you’re wondering why that is, you’re not alone. And while there’s not much that can be done about making the insurance companies change their ways, you can gain a better understanding of dental coverage to be better prepared.

Why doesn’t my dental insurance cover the entire cost of my dental treatment?

Dental insurance isn’t meant to cover the full cost of any given dental treatment. Dental insurance is a monetary benefit, that may be provided by your employer, to help you pay for dental treatment. Most dental insurance plans are designed to only cover a portion of the cost.

We’ve already talked about how yearly maximums have stayed the same for almost 50 years, in fact, if they would’ve been adjusted for inflation you’d have at least $5,000 in yearly maximums. Thus, it’s imperative for people to understand their dental insurance is only intended as an aid.

If my insurance isn’t going to cover everything, why does it say that this procedure is covered at 100%?

When a dental insurance says that they pay 100 percent of a procedure, they mean that they cover 100 percent of what the insurance provider allows as payment towards that procedure.

That may sound like Greek to you, so let us explain. Say that your provider allows $70.00 as the 100 percent payment for an examination, but your dentist charges $85.00 for the examination. This means that they are paying 100% of $70.00 and that you will owe the remaining $15.00.

Why are my dentist’s fees different from the insurance company’s?

Insurance companies never reveal how they determine “usual, customary, and reasonable” fees, as they put it.

There was a survey done in Washington state that found eight different fee schedules for one zip code! Thus, the best guess is they randomly assign an average fee for a particular procedure in a geographic area.

However, average has been defined as the “worst of the best,” or alternatively, the “best of the worst.” And who really wants average dentistry?

Your dentist has set their fees in accordance with the quality of care they provide, the education and skill of the dentist & the team, the quality of technology in their office, the quality of materials they use, and so on.

You truly get what you pay for. You wouldn’t expect to pay $10 for the real statue of David by legendary artist Michelangelo, would you?

So you shouldn’t expect all dentists and dental offices to be the same in fees or the quality of care they provide. Because dentists are not all the same. (But you’re a smart cookie so you knew that already, didn’t you?)

Why aren’t dental offices better at estimating?

The simple answer is that insurance companies make it very difficult to do so.

Unless your dentist has an agreement with the insurance provider, the insurance provider does not/will not share their fees. So remember that hypothetical $70 exam we talked about at 100%? This is the actual information your dentist has: 100% of _____. Translation: you receive a bill for $15 because the dentist didn’t know what the insurance was actually going to pay.

To make matters more complicated, the insurance provider also adds limitations or allowances to your plan. For example, they may only pay for (a portion of) a crown every 5 years. If that detail was missed, you might’ve been anticipating them to pay something and instead they pay nothing.

It’s also important to understand that these limitations vary from person to person. So Jane Doe who works at the same company may have her limitation set to every 3 years, while yours is 5 years.

Further, the insurance company defines what category a procedure is in. For example, you’ve had a dental cleaning done and the “preventative” category is at 100%. But technically your dental cleanings are more involved so that service has a different service code applied to it, which makes it fall under the “Periodontics” category which is at 50%.

Confused yet? That’s how your dental office team feels too.

Now, add 1,000 plus patients to that mix—most with different plans, maximums, companies, coverages, limitations, allowances, fee schedules, service codes, hundreds of procedures, etc.

It’s pretty impossible for a dental office to know all of that information, particularly when the insurance companies don’t allow the dentists to access most of the information.

The bottom line is: Your dentist does not work for the insurance companies so they don’t truly know what insurance will actually pay.

They do their best to unravel and solve the mystery which is dental insurance in spite of the challenge that it is, but at the end of the day, they are really there to help you be healthy.

You want a dentist who cares about you & your health needs and not one who worries about what a 3rd party company is willing to pay.


What the Heck Is Up With Dental Insurance Benefits?

There’s a light at the end of the tunnel.

The good news is that you are the insurance company’s client, and you have access to all of the information that they will not provide to your dentist. The best way to get a more accurate estimation is to take charge yourself:

  • Know your plan’s yearly maximum.
  • Know your plan’s fees and percentages.
  • Discover any hidden limitations or waiting periods.
  • Know if you have a deductible or co-pay & understand that is usually per person on a plan.
  • Keep track of what benefits you have used at your general dentist or at a specialist’s office (other offices don’t call and update your dentist on used benefits.).
  • Know if your insurance provider covers the quality of treatment you deserve — insurance companies will often “downgrade” in order to pay less. Example: they will cover a metal crown at a lower fee, rather than a better porcelain crown. If they do not, go to your HR and raise the complaint. You deserve dental restorations that don’t harm your health, like the mercury restorations insurance pays for!
  • Explore other payment options to help with the inevitable out-of-pocket expenses (remember insurance is only an aid, not a full ride).

If my insurance doesn’t cover this treatment, should I do it?

Never, never let what insurance will and won’t cover dictate what dental treatment you choose. Many routine dental services are not covered by insurance companies. However, this does not mean that the treatment is not necessary or appropriate.

It is the dentist’s responsibility to recommend the dental treatments that are best for your health and your smile.

Your insurance provider on the other hand, has the sole responsibility of controlling payments. If you were to lose a tooth because of neglecting to have the proper treatment performed, chances are you would pay anything to get it back.

And it isn’t just your smile and health that neglect affects, it’s your wallet as well.

After being in dentistry for over 30 years, we’ve seen this happen more times then we can count: a patient will put off getting restorative treatment done because their insurance won’t cover it. Then the tooth abscesses and they need a root canal. That root canal uses all of the insurance benefits, and the patient still has to pay for the restoration out of pocket!

So now treatment that was only $1,200 to begin with has become $4,000 or more — costing the patient a lot more in time and money. This is sad, really, because that is something that could have been avoided.

Like we tell all of our patients: it will never cost less or hurt less than it does today.

Having recommended treatment done when it’s recommended is an investment in your health that will save you time, money, and pain in the long-run. 

Why should I bother with insurance if I always have to pay out of pocket when I go to the dentist?

Remember that even though dental insurance may not cover the entire cost of a dental procedure, it still covers something. This lessens your out-of-pocket expenses. A penny saved is a penny earned, as they say! We do, however, recommend that you consider what your premiums are. Sometimes it doesn’t make sense for a person to have dental insurance, and is much more cost effective to have a personal dental savings account.

We hope we were able to help you understand how insurance works and we encourage you to come to us with all of your dental insurance questions. To schedule a complimentary consultation with our office in [city], [state], please contact us at [phone] today.

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