Being a PPO dentist I wish I had a dime for every time a patient asked ‘Does my insurance cover this?’ If I did, I could buy 10 new handicap ramps since ours was stolen from our premises this year (true story)! At a time where words can have different meanings to different people I want to dissect what a patient could be asking when they say, “Does my insurance cover it?”
From my experience patients are asking really 2 things. Firstly, they are asking, is it 100% paid for by insurance? Secondly, will our office guarantee that? What patients do not realize is that neither the patient nor the provider have ultimate control of what the insurance will pay for (if paying for anything at all). The insurance ultimately controls this AFTER the services are completed. The insurance company pays what they believe they are liable for and the patient pays what is not covered to the doctor. The doctor may be obligated to write off a few of these services depending on the agreement but this is rare. Both the patient and provider sign contracts with the insurance company agreeing to these terms. So why are patients asking providers, “Does my insurance cover it?” when the truth is we do not know for sure until after the work is done and the insurance processes the claim? We are not the insurance, but the provider, and we do not have the authority to guarantee payment.
One reason I believe this crazy cycle of confusion exists is from something insurances are producing called an EOB. An EOB is an “ESTIMATION Of Benefits”. The key word here is ESTIMATION. Patients read their EOB’s and they are confused into believing these estimates are guarantees of coverage. I am listing some common scenarios I have experienced where insurances actually do not cover dental service fees.
1. Deductible – the service rendered has an unmet deductible. People are shocked this sometimes includes emergency visits, x-rays, and most dental work and range from $25 to $100 per year.
2. Percentage coverage – some services are only covered at a certain percent of the fee used. We are seeing now even cleanings are sometimes being covered only 90%, and perio maintenance cleanings at 80%. Common percentages are fillings and extractions at 80%, and crowns and dentures at 50%.
3. Maximum allowance – the patient has used the $1000 they were allowed to use for the year and the rest is out of pocket. This $1000 can be hit after 1 molar root canal and crown in some cases. If they receive a cleaning during the same financial cycle, the cleaning will not be covered usually.
4. Fee used to calculate coverage – If insurance is out of network the fee used to calculate coverage is usually a lower fee than the provider fee. They us the insurance fee to calculate but you are entitled to your UCR fee. So 80% coverage can quickly turn into 50% coverage.
5. Frequency limit – After one thing is done it can’t be done again for a fixed amount of time or will be out of pocket. Examples include 2 exams a year, 1 full mouth set of x-rays every 5 years, Bitewing x-rays 1x/year, fillings on same tooth 1 every 2 years. If these limits are exceeded the insurance can deny coverage and the patient is responsible to pay in many cases.
6. Downgrades – The insurance has the right to pick the least expensive option and use that to calculate the patient's benefits. (All metal crowns vs. porcelain crowns, silver fillings vs. white fillings, denture versus implant, etc). This will lead to less coverage and patients want the option to pick the cheaper option in many cases or will frustrate your front desk.
7. Coverage is terminated or expired – Employers are eager to save on dental insurance plans. I have had employers cancel plans retroactively (so there was no way for us to guarantee active coverage unless time travel was possible).
8. Tooth exclusion or missing tooth clause – This is when the tooth was missing prior to insurance being activated. (Common with implant or bridge coverage denials).
9. Non-covered expense – there are many procedure codes in the CDT system. Most insurances only cover a basic portion of these. The patient is expected to pay non covered expenses out of pocket at the UCR doctor fee. Patients assume they get the insurance fee if something is not covered but this is not always true.
10. Non-restorable denial – An insurance company can deny coverage based on a disagreement on whether they believe the procedure should have been done due to restorability. This is hard to believe as they have not examined the patient, but I have seen this happen in our office.
11. Prior billing errors – Some dentist offices have incorrectly billed extractions or other work. When the patient goes to a ‘better organized’ office and the correct teeth are billed the insurance can deny payment based on inconsistencies with prior billed services (happened to us as well!).
12. Primary and secondary issues - If your dentist is in network with your secondary but not in network with your primary insurance the secondary can deny coverage based on incomplete processed primary coverage. Insurance law dictates which insurance is your primary and secondary insurance not the dental office. It really is the patient's reponsibility to notify the dentist of all insurances they are participating with.
13. Insurance criteria for coverage – Periodontal scaling or root planning can be denied if the insurance does not believe the pockets are big enough or there is not enough bone or attachment loss. Are we then supposed to wait for the gum disease to get worse?
14. Limit on replacement coverage – Insurances will demand past dental records of the patient prior to coverage of a failing bridge. They want to see records showing the bridge was done more than 5 years ago. It can be difficult to obtain these records and also can significantly delay treatment.
15. Out of network or non-participating – some of our patients freely change insurances mid treatment and even within their own Insurance carrier during open enrollment (going from PPO to DMO) and end up with no coverage since we do not participate with DMO Plans. This is very difficult for a dental office to catch and should be the patient’s responsibility to inform the office if they are going to make any changes to their insurance plan.
16. Lab surcharges - patients have the expectation that the fees the insurances use to calculate coverage will assume any upgrades to the quality of dental care the patient or doctor is choosing to complete treatment. Dental implant restorations done in the anterior can result in black triangles, metal showing on areas not wanted, and poor access if the implant screw get's loose. These problems could and can be solved with upgraded options in restorative implant dentistry. I make sure my patients are informed of the estimated costs of these upgrades so there are no surprises of course. I also make sure the surcharge are in fact a devation from basic lab costs as they are entitled to a standard treatment option with no lab surcharge.
After reading this you should be overwhelmed! Well I guess that is really the point. Now when a patient asks ‘Does my insurance cover it?’ we hope they are implying that we have 20-30 minutes to grab a cup of coffee and discuss it with them. Otherwise we hope that they ask, ‘What is an estimation of benefits? We can answer that in 5 minutes after looking up some of their information but it is only an estimation. I recommend patients are informed of an ‘estimation if covered’ and an ‘estimation if not covered’. This at least gets the patient a worst case scenario before moving forward with treatment. Also if time is not an issue for you ask the office if a predetermination can be done to get more specifics on estimates for work that may cost in excess of $400. This is a very reasonable request. Thank you insurance companies for keeping us busy with managing your benefits and not doing dentistry! In all seriousness as complex and frustrating as it can be, actually I'm am appreciative of dental insurances. At the end of the day without dental insurance my practice would be cut in half most likely!
Dr. Maq Serang, DMD
CEO, Serang Dental Associates
The dental insurance industry, while providing increasing access to dental care, has become a major challenge for today’s dentists. Payment denials, shortened procedure time allowances, and decisions on material usage are only a few of the frustrations dentists are facing from insurance companies. Maintaining quality care and, at the same time, satisfying insurance guidelines can cause a sense of exasperation in patients and a sense of burnout in the best of dentists. Serang Dental Associates will not compromise quality dental care regardless of insurance industry decisions or regulations.
A dentist’s customary fees are calculated to allow for the time spent with the patient, office and equipment overhead, and the execution of superior staff performance. Patients as well as dentists can become frustrated when payment expectations are not met, out of pocket expenses rise and an “out of network” quality dentist becomes unattainable. As a result, fewer dentists are willing to accept discount driven dental insurance companies with such policies. When insurance companies allow only 40-80% reimbursement of the calculated fees, the best option is to consider dropping those companies.
While there is not an easy solution to these problems, there are options to consider. With effective discussion, I have seen insurance companies agree to higher reimbursements to cover actual dental fees. However, when insurance companies are not willing to give reasonable compensation, dentists may need to treat more than eight patients in an eight-hour day. Educating patients about insurance limitations can expand their awareness of other possible options. To keep informed of changes in the insurance industry, Serang Dental Associates will re-evaluate our participating insurance companies on a yearly basis to make certain our practice is being helped and not hurt by their policies.
I am also committed to recruiting and maintaining a strong team of talented and trained staff members including hygienists, expanded function dental assistants, and versatile administrators. Such a superior dental team is more prepared to meet the growing demands of insurance billing as well as all phases of general dentistry, and I believe a strong team can help overcome the adverse economic conditions the dental field produces.
Patients may indeed need to pay more out of pocket expenses for involved procedures, especially if they belong to a discount dental plan. However, we at Serang Dental Associates desire to lessen the financial strain on our patients as much as possible. We plan to utilize advanced computer technologies, so patients will have a reasonable estimate of costs before work is completed. We will also willingly offer alternative treatment options to fit most budgets.
Quality dental care is non-negotiable! Serang Dental Associates will not compromise its standard of quality care. We strive to develop an honest and fair relationship with each of our patients and to make your experience with us as pleasant and economical as possible.
Dr. Maq Serang, DMD
CEO, Serang Dental Associates
I have gotten that question multiple times in my office regarding why dental implants are being advertised for $600 as opposed to our estimates which can average $3500 per tooth!
Assuming the philosophy, "you pay for what you get", has already been exhausted, there are many factors to consider when getting a dental implant. I will list a few of the things I have observed that affect the quality of implant. By quality I do mean you do not have problems with them as early as 3-5 years. An implant comes in 3 parts, implant body, implant abutment and implant crown. Below are a few things to consider when deciding to move forward with a dental implant tooth replacement.
1. The surgeon placing the implant body is very important in my opinion.
Have they placed implants successfully for many years and are they honest about this from the beginning? (3-5 years)
Do they take precautions to place it in the right location? (Cone beam xray)
Are they selecting the right thickness and length of implant? (Cone beam x-ray or utilizing gauges to measure bone or extracted root thickness).
Are they selecting a reputable implant company with good support from the company?
Are they keeping to placing implants based on their training? If they are getting started placing implants are they case selective and able to select simple cases with you while also offering the use of a specialist?
Did they make sure adequate bone was available before placement and discussed the extra costs for bone grafting or sinus lifts?
Was a Cone Beam CT scanner used to obtain the bone in the 3-D in order to study ideal placement, vital structures, bone denstiy and implant size?
Do they take precautions to avoid vital facial anatomy, like the maxillary sinus, inferior alveolar nerve, mental nerve, and perforation past bone as to limit risk of complication?(Cone Beam CT Scanning)
Are they utilizing current techniques is bone grafting, membrane placement and tissue management where needed(emergence profile)?
Here are a few things to consider regarding implant body. With hundreds of dental implants on the market, it is recommended to be using the type of implant that has a strong customer support team, solid research proving it's success, flexibility to adapt to unique situations (bone level vs. tissue level, mini-implant, etc, etched surface for better osseo-integration), threading to allow ideal primary stability of the implant at placement. Generic or less know companies producing implants may be available but in 5-10 years they may be out of business or hard to get in contact with since they may have discontinued production or discontinued earlier models(I've run into this restoring an implant system I will not choose to mention here).
3. Here are a few things to consider regarding the implant abutment. Ever heard of failure due to dental cement excess, or failure due to a loose abutment from a weakened screw. Well if the abutment was a screw retained abutment vs. solid abutment life has gotten a lot easier for you. Removal becomes very predictable and most of the time inexpensive. Did they use implant abutments that are manufactured from the same implant body company as to avoid errors in fitting and not void the warranty or increase chances of loose abutments?
4. The implant crown. Is it screw retained or cement retained? Did the dentist take the extra precautions to limit the excess cement around the implant? Did they offer a screw retained option vs. cement retained to allow access easy access to the screw if the abutment get's loose and decrease risks of complications due to cement? Are they keeping good records so in 8 years there is a problem the solution can sometimes be a simple implant maintenance visit versus having to redo the whole abutment and crown.
Not to overwhelm the patient but I do encourage knowledge. Not all implant cases are done with the same level of quality and concern as they should. I do believe some specialists are not always perfect either and few can be caught charging high costs for implants. That being said I also feel cutting corners to go with the cheapest dentist can sometimes result in getting what you pay for.
Another note, after calling a few of the offices that advertise 'cheaper' implants I found they were only pricing out the first step of the implant process and that was only given after a consult concluded it was an 'basic' case. If not so 'basic' you would be given the 'real' cost of the implant. So $600 was only the implant body but the abutment and crown resulted in a total of $2800-$3000. A little misleading if you ask me!
Best of luck on your journey to good oral health. We are always happy to give a second opinion on any cases out there so feel free to call the office number and set up an appointment. I am always happy to tell people they do have an excellent dentist and encourage them to stay with them if they found one!
Dr. Maq Serang, DMD
CEO, Serang Dental Associates