The “Missing Tooth Clause”
For Business Coordinators, Insurance Coordinators and Treatment Coordinators, the “missing tooth clause” strikes a sour note when it comes to presenting dental treatment to patients. If anything should be covered by dental insurance, wouldn’t it be replacing missing teeth? Unfortunately, approximately 90% of dental benefit plans will not pay to replace a missing tooth that was extracted prior to the coverage date of the patient. This is good protection for the insurance company, but sends the wrong message to patients. If the insurance company states in its policy that there will be no benefit dollars for the fixed partial dentures (bridgework) or implant, it may be interpreted as “if the insurance won’t pay then I don’t really need it.”
The negative consequences of losing supporting bone and the shifting of other teeth in the jaw - which can cause jaw misalignment pain and also accelerate the loss of more teeth - is of no concern to the insurance company. Many people suffer from low social morale and embarrassment from missing teeth, causing them to avoid people or cover their mouth when speaking - this is of no concern to the insurance companies either. The question to ask your patient is this: “Can you eat without teeth?” For the most part, the answer would be “yes” - but the question can open up a line of conversation about the quality of their oral health.
For those who are missing teeth here and there, it may not seem like such a big deal, especially if the toothless area is not visible when smiling or eating. Patients can learn to live with discomfort and can avoid foods they love if they can’t chew them properly. But people with missing teeth eventually suffer from the “sunken face” aged look, often long before they are truly old. Other complications can arise from not being able to crush and chew food thoroughly enough for proper enjoyment and digestion. Explaining these facts and illustrating them with photos and other educational aides is the responsibility of the dental professional - but it still doesn’t replace the fact that the patient is not going to receive dental benefits.
It can be confusing to patients who are trying to understand why the coverage is not there. The patient can be directed to bring this to the attention of his/her employer with the hope of getting a policy without the “missing tooth clause”. It can also be helpful to point out to the patient that even if replacing the tooth/teeth was covered in their policy, there would still be an out-of-pocket cost subject to a yearly plan benefit maximum. Instead of immediately drawing attention to the existence of the “missing tooth clause” you might consider asking this question: “Despite the fact that this policy is limited to coverage of preventive and basic services, would you feel more confident and enjoy life more if you could have your missing teeth back?”
This is a closed-end question but can be explored with the patient whether it is answered yes or no. If the answer is “yes” then this will lead into presenting the most favorable treatment options and presenting financing choices like affordable payments with CareCredit or a reduction in fee if paid in full at the time of treatment. When the question of insurance coverage comes up, the explanation might go like this: “Your benefits through this policy are for prevention of disease and basic repair services to existing teeth such as fillings and crowns. Pre-existing conditions such as missing teeth are not covered. Benefits of $_____ are estimated to be paid for your cleaning, x-rays, examination and tooth colored fillings. The partial is not a covered benefit.”
Many people would not seek dental care if it weren’t for dental benefits offered by their employer, even as limited as they are. The challenge of bringing value to services outside the realm of coverage can be improved with professional training in treatment acceptance and communications. Want to learn more about increasing treatment acceptance? Join us today for professional training, and end the frustration of unscheduled treatment. Details can be found HERE.Forward this article to a friend
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