First trip to the dentist?

All recommended treatment during your dental visit is elective, unless you are in pain. In addition, there are numerous treatment options for each dental condition. These will vary in cost, treatment time and durability. For example, a missing tooth could be replaced by a partial denture (removable plate), a bridge (cemented) or a dental implant. The dentist will explain your treatment choices, the limitations and advantages of each and together decide on the best treatment for you. You and your dentist will prioritize those procedures which are necessary from those which are cosmetic and/or elective. As a thorough treatment plan can be costly, treatment can be phased over time, addressing those procedures which need urgent attention first.

Before you seek any treatment, make sure you understand the costs involved and when payment is due. Make sure that the dentist accepts your dental insurance first before arriving for your appointment. Do not automatically assume that your dental insurance will cover everything. Understand that even with insurance a good portion of the costs may be your responsibility. Insurance Companies are in business to make money, not to give you the finest marvels of modern dentistry but the least expensive way to treat a dental condition.

Most insurance plans have restrictions which limit your eligible coverage. These would be in the form of deductibles, co-payments, waiting periods, annual or lifetime maximums and exclusions. You need to ask your insurance co. what these exclusions are. For example, most will cover the silver fillings but not the white composite restorations. The amount of dental coverage you have is negotiated between your employer and the insurance company. Any questions regarding limitations in coverage should be directed to your employer and not your dentist. While benefits should be taken into account, it should not be the deciding factor in your choice of treatment. You should base your treatment around your dental needs and not your dental plan.

The dentist submits "your" insurance claim at no cost and as a courtesy to you. They will usually provide you with an estimate that will show expected insurance reimbursement and your share of the costs for every procedure. This share is due at the time of treatment unless prior arrangements have been made. Should no insurance payment be made within 60 days of a submitted claim, the fee will become the sole responsibility of the patient. Some dental offices require payment in full from you at the time of services and will forward the insurance payment to you once received. The insurance information obtained for you by the dental office is a guideline only and is no guarantee of payment. You are ultimately responsible for all payments. The only way to obtain written coverage for your proposed treatment is to preauthorize it with the insurance carrier. This predetermination of benefits is still not a guarantee of payment. This usually takes 6 weeks, which may not be in your best interest to delay urgent dental treatment.

If you are uncertain whether to proceed with the recommended treatment get a second opinion (find a dentist) or you can call the local dental society in your area for a referral (find dental societies). If you feel that you have been improperly treated or dissatisfied with the level of care you received, you can contact your state or local dental organization, which usually offers peer review to mediate disputes between patients and dentists. These services are available free of charge to patients.

What is Dental Insurance?

Dental insurance is one of the most beneficial and most misunderstood factors in dental treatment today. This explanation will attempt to clear up many common misconceptions about dental insurance.

Dental insurance is a contract between the employer and the patient. It has NO CONNECTION at all to the provider of dental treatment(the dentist). The extent of coverage varies greatly from company to company, and sometimes even within a company. It has absolutely nothing to do with the level of service provided by the dentist and the fee charged for these services.

An often misunderstood term used by insurance companies is "UCR". This is an arbitrary fee ceiling at which the insurance company will stop reimbursement. After this ceiling, coverage for a particular procedure will cease. Again, this has nothing to do with the fee charged, but with the level of coverage negotiated by your employer.

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Dental Insurance Categories

There are four main categories of dental insurance:

• Indemnity

• P.P.O. (preferred provider organization)

• H.M.O. (health maintenance organization)

• Direct Reimbursement (self -insured)

Both a Direct Reimbursement program and an Indemnity plan recommended and endorsed by dentist.net allow you to see the dentist of your choice without any restrictions. A Preferred Provider Organization otherwise known as a P.P.O. is a financial agreement between the insurance company and the dentist, whereby the dentist agrees to lower his fees to meet a prescribed fee schedule administered by the dental insurance company and sold to your employer for a reduced insurance premium. You are given a list of providers who honor the P.P.O. program. Most patients assume that you must see a provider on the list only and this is NOT true. What insurance companies fail to convey, is that you can still visit the dentist of your choice BUT it will cost you more as a non P.P.O. dentist has not signed your insurance companies reduced fee contract.

Also known as Capitation plans, H.M.O's are generally programs, by which you, as a patient pay little or nothing out of pocket for your dental needs. Your dentist, chosen off a list, is reimbursed monthly at a small flat rate per patient. This money is received even if the patient does not come in or has no treatment done. You must leave the dentist with whom you have established a relationship and choose a new dentist from a list supplied by your employer. Unlike a P.P.O. plan, you can only visit dentists who have contracted with the H.M.O.

Dentist.net believes that these programs are based on a principle where the dentist is placed in a financially advantageous position if he or she performs little or compromised treatment on a patient. Furthermore, the dentist benefits to an even greater degree if the patient never comes in at all. Here are some paraphrased excerpts from a Dental Association newsletter sharing the Association President's views on these plans:

" I finally concluded…. it is extraordinarily difficult to maintain quality, honesty, and consistency and still make a living with these programs. In order to break even with these programs, you must: discourage treatment of early cavities, downgrade the classification of periodontal disease, extend amalgam fillings to more surfaces than the cavity calls for, not schedule recall visits, allow appointments only during the least desirable times, and basically do as little as possible. What good will I be if I skimp on quality, intentionally under-diagnose, and operate dishonestly?"

NiceDentist.com encourage regular preventative visits and optimum treatment. We feel that we take the necessary time that each patient requires to get them to the best state of oral health while maintaining a friendly, relaxed, and most of all, personal atmosphere. We truly care for every single patient, and your continued feedback, compliments, and referral of friends and family always make us proud. We strive to provide you with top quality comprehensive care at a reasonable fee. It is unfortunate that many of these cost cutting insurance plans cannot allow us to do so.

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What is Direct Reimbursement?

It has widely been accepted that insurance benefited the dental profession by allowing patients to receive treatment that they might not be able to afford on their own. With the cost of coverage escalating, many dentists question whether insurance is still the asset that it once was. Some have even begun to wonder if insurance should be involved in dentistry at all. The Insurance Companies have responded by promoting Preferred Provider Plans (PPO`s) and HMO`s which eliminates your employees freedom to pick their own health care professional and drastically reduce payments to providers resulting in long waits for dental appointments and less than satisfactory dental care.

Insurance, by definition, protects against a potentially catastrophic loss that is impossible to predict. That's why you need life insurance, medical insurance and long term disability insurance. But dental treatment is highly predictable and non- catastrophic. It's prevention orientated. It involves frequent claims of relatively small dollar amounts. Most dental plans sold by insurance companies, have an annual maximum benefit of $1000 or $1,500. It is clear that they are not designed to protect against catastrophic expenses, but to assist you with routine expenses. Since dental benefits aren't really insurance, it's not necessary to involve insurance companies in the dental benefits loop. You don't need to insure a routine expense that is predictable and budgetable. Insuring yourself for dental expenses is like insuring against haircuts or utility bills!.

According to the American Dental Association only 50-60% of people who have dental benefits ever visit the dentist in a given year. Less than 5% who have dental plans with a $1000 annual maximum benefit actually reach the maximum benefit each year. The average dental expenditure per person in the United States is less than $160 a year. Less than 5% of the total health care dollar is spent on dental treatment. Many don`t realize that 50% of the dentistry performed in this county is still paid for out of pocket by the patient. Yet, in spite of these figures, many employers still believe that they need the security of an insurance company in order to provide a dental benefit for their employees.

What many fail to realize is that an insurance company costs (overhead and profits) can consume up to one third of the premiums an employer pays for a traditional dental plan. By being self insured or self funding you eliminate the insurance company and many of the expenses associated with it, resulting in a savings of 19 -29 percent compared to many fully insured plans.

A self funding company has two ways to administer dental benefits. Implement a company traditional dental insurance plan which would need to be handled by a third party administrator with administrative costs between 7% to 14%, or a direct reimbursement (D.R) plan which would reimburse the employee a percentage of the dental services rendered. D.R. which is strongly supported by the American Dental Association shows administration costs of 3.5% to 7.5%, about one-half of the administration cost of a traditional self-funded plan.

Direct Reimbursement (D.R.) is a simple method an employee can use to provide dental benefits for their employees without an insurance company involvement. The employer selects or customizes a reimbursement plan that suits their budget or needs. Benefits are typically stated in dollars as a percentage of the expenses incurred, up to the limit of an annual maximum which is determined by the employer. Employees visit the dentist of their choice and pay for the treatment they receive. They then present a paid receipt to their employer who reimburse them for all or part of the expense incurred. Below is an example of a D.R. plan

Dental Expenses	Employer Pays	Employee Pays	Eligible Benefit
First $100	100%	0%	$100
Next $500	80%	20%	$400
Next $1000	50%	50%	$500
Annual Maximum Allowance per person:			$1000

 

 

 

 

This method ensures that the plan pays only for actual dental services received, that employees go to the dentist of their choice, and that virtually all of the monies spent go for dental treatment. The variation of the different plans is limited only by the degree of financial commitment the employer is prepared to make. An employer may begin its plan by offering a conservative annual maximum, and then revise the benefits level at any time.

As dentists we are constantly sandwiched between the Patient and the Insurance Companies. In many situations treatment rendered is tailored around what benefits are covered, which may not be in the patients best interest. Patients should be able to receive treatment that best meets their needs without third party intervention. Direct Reimbursement emphasizes direct employee to employer, patient to dentist relationship. Employers realize savings by eliminating costs due to complicated claims adjudication, service restrictions and exclusions, participating provider lists and insurance company profits. Besides the cost savings, the D.R. concept usually means an increase in benefits to the employees. Traditional plan designs contain deductibles, waiting periods, UCR limitations and excluded procedures that dramatically reduce the benefits available to employees. D.R. plans eliminate most of the limitations that reduce benefits. Most traditional plans reimburse on average 54% of the patients actual expense, while employees covered by D.R. plans are covered between 64% to 77% of their actual expense. The higher benefit levels are affordable to the employer as a result of the reduced administrative fees and the employee's prudent use of dental services.

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