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  03.17.05 Issue #158


My Insurance Pays 100% for my Treatment: Answers to This and Other Patient Myths

Carol Tekavec, RDH

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Patients have many questions regarding their dental benefits. While it is actually the patient’s responsibility to deal with his/her own insurance issues; the fact is that few patients understand their plans. The dental office personnel often end up having to “fill in the blanks” as to what a patient can expect.

How can staff deal with common patient questions? Is there a way to prepare patients for the limited nature of dental insurance without focusing on the “negative”? One answer is to use “positively” written materials, such as a brochure or information sheet, that can address widespread patient misconceptions while supporting staff explanations. When a brochure discusses insurance in simple terms, the patient sees that the staff is not “just making this stuff up as they go along.” Patients can read the materials and take them home to go over later.

Let’s look at a few common questions/myths that might be addressed:

Q: Why doesn’t my insurance cover all the costs for my dental treatment?
A: Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.

Q: But my plan says that my exams and certain other treatments are paid for 100%!
A: That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge. Typically there is always a certain amount left for the patient to pay.

Q: If I always have a balance to pay, what good is my insurance?
A: Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something. Any amount covered reduces what you have to pay out of pocket. It helps!

Q: I received an Explanation of Benefits statement from my insurance carrier that says my dental bill exceeded the “usual and customary”. Does this mean that my dentist is charging more than he/she should?
A: What insurance carriers call “usual and customary” is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. (This amount is typically based on the premium cost for the employee and how many services the plan will cover.) The “usual and customary” is usually less and frequently much less than what any dentist in your area might actually charge for a dental procedure. It does not mean that your dentist is charging too much.

Q: Why won’t my insurance pay anything toward some procedures, such as x-rays, cleanings, and gum treatments?
A: Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of x-rays, cleanings, and gum treatments it will cover because these are the types of treatments that many people need to have frequently. Too many payments for these services would make the premium cost higher.

Q: If my insurance doesn’t cover it, I don’t need it…right?
A: It is important to know that each contract will specify what types of procedures are considered for benefits. Even if a procedure is medically and dentally necessary, it may be excluded from your contract. This does not mean that you do not need the procedure. It simply means that your plan will not consider the procedure for payment. It is a mistake to let benefits be your sole consideration when you determine what you want to do about your dental conditions. Your health is important!

Talking to patients about their dental insurance can be tough, but there are rewards. Current studies show that patients with insurance see the dentist more frequently, and have more treatment accomplished than patients without insurance. Without insurance, most middle class patients would be unable to afford dental treatment. Insurance helps patients receive the care they need.

For more information on “My Insurance Covers This….Right?” go here.

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Apr. 15 Destin, FL Excellence in Dentistry Sally McKenzie & Exhibit
Apr. 21 Nashville, TN American Academy of Cosmetic Dentistry Sally McKenzie & Exhibit

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