Dental Insurance

What is Dental Insurance?

Dental Insurance Categories

What is Direct Reimbursement?

We accept all indemnity insurance plans and the PPO plans below. We do NOT accept any HMO, DMO or capitation plans. For more info, please call our office at (949) 552-6334.

CARRINGTON (some plans)
At our office, our patients understand and sign a notice that says that we file insurance as a courtesy. We also check eligibility and benefits as courtesy using either an on-line service or by telephone. But the Insurance company will tell you that eligibility and benefits given is NOT a guarantee for payment. We do our very best to get accurate insurance benefits. ThatÕs why we tell our patients that the Insurance policy and its benefits are between you and your insurance company. We do not claim nor take responsibility for the patients benefit package. The patient is always ultimately responsible for the cost of services rendered to them and for knowing how much the insurance will pay

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.

Back to Top

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 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.

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?” 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.

Back to Top

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 Employer 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.

Back to Top


CareCredit for dental procedures

We’re pleased to offer our patients the CareCredit card, North America’s leading patient payment program. CareCredit lets you begin your treatment immediately – then pay for it over time with low monthly payments that fit easily into your monthly budget. Now you don’t have to save up for years to finally get the smile you’ve always wanted. Learn more by visiting or contacting our office. Ready to apply? Apply online for your CareCredit card today.

The Wells Fargo Health Advantage card gives you the flexibility to pay over time for care. Learn more by visiting