How Dental Insurance Works

The term “dental insurance” is not exact. A more accurate term would be “dental benefits.” Misunderstandings about the expected insurance payments, and the patient’s responsibility for co-payments, are a potential source of conflict between dental staff and patients. Dental insurance is not insurance in the traditional way we expect insurance to work. If you bought an insurance policy for your house and it burns to the ground, you would expect your insurance to cover the rebuilding of an equivalent house. If your tooth broke, you would expect “dental insurance” to pay for its replacement.

If a patient wants some dental service and has what is considered “good insurance” and expects most of their fees to be covered, the conversation may go like this.

“How much does my insurance pay for a crown.”

“Since this is major work, it would be fifty percent of the UCR minus your $50 deductible.”

The insurance company determines UCR (Usual, Customary, and Reasonable) fees, and the patient can misunderstand them. The fact of the matter is that the UCR for a particular zip code is different for different insurance companies, and so it is clear that they are not using the same statistics to determine UCR.

The insurance company will not tell you how they determine what a crown should cost in your zip code. They are a for-profit business, and they have to pay out less than they receive to remain solvent. A patient’s benefits are related to actuarial tables and how much money the insurance company collected for premiums. If you are part of a PPO (Preferred Provider Organization), you may receive a schedule of services that the plan will consider for reimbursement. You have no recourse if a preventive service is not covered; you will have to pay for it.

Out of Network Providers

You will be considered “out of network” if you go to a dentist who is not signed up with the network, and the consequences will be lower reimbursement. Patients who understand this model should know the patient’s benefits or the diagnosis is their responsibility, and they have to decide their course of treatment even if it costs them more.

Dental Reimbursement Plans

Direct reimbursement plans repay patients for dental work they have already paid for, using a formula that allows patients to direct where they spend their money. The freedom patients have to choose their dentist and how the reimbursement is allocated has increased this type of plan’s popularity. The American Dental Association has provided information for its membership to encourage patients to solicit their employers to consider this type of plan.

Dental benefit plans that allow you to use any dentist will also have a fee schedule. Still, you will not necessarily know all of the reimbursement fees unless you do a predetermination of benefits. Many states have insurance commissioners who will support you in your right to receive a benefit if you were entitled, even if there was no predetermination.

Some people use the excuse “I don’t have dental insurance” because they do not take care of their teeth. The correct term that represents the dental plans is “dental benefits.”

Employer Dental Plans

When your employer shops for benefits, they compare premiums and consider benefits. Some benefits are sold as PPOs (Preferred Provider Organization), where dentists sign up to accept decreased fees in return for a listing in the plan and more patients. The reduced costs are usually about 20 percent less than UCR (usual customary reasonable) and may require the dental office to cut overhead in some way to maintain a reasonable profit. Many good dentists accept PPOs as a service to their patients. The contracts are very strict; some services are not covered, and the dentists can charge their total fees if their patients want a service that is not covered. The contracts are long term, and the major ethical dilemma for me as a dentist when I accepted these plans came when the patient wanted what the insurance paid for, and I knew that was not the best treatment for their diagnosis.

Patients should choose their doctor deliberately and not because “I have no choice; they accept my plan.” In the early days of dental insurance, “But you take my insurance” meant “Please do your billing, so I do not have to pay anything out of pocket.” That is unethical.

When the insurance company sets the fee that the doctor will accept and only pays a part of that fee, the patient must pay the balance. If the price for a root canal set by the insurance company is $800 and they pay $640 minus $50 deductible, meaning a net payment of $590, the patient is responsible for paying the $210. Patients nowadays understand how insurance benefits are paid and set their budgets for dental services accordingly.

As DNA studies have improved, so has our understanding of the disease processes that affect oral structures.

Some of the pathogens that cause the most severe gum diseases can be passed from one family member to another through direct or indirect means: directly by kissing or indirectly by sharing utensils. The kind act of a mother cooling soup to feed to her infant child or tasting the food before she feeds her child could transfer infectious pathogens that lead to advanced disease (e.g., A.A. Actinomycoses Actinomycetemcommitans a significant pathogen for periodontal disease). The patient’s dental care and oral hygiene program, or lack thereof, influences how well the germs take root in the space between tooth and gum.

Leftover food between the teeth and gum, plus the mouth’s warmth, allows pathogens to thrive. The body sets up the immune response, and the by-products produced and excreted leads to a breakdown of bone and supporting tissues—loose teeth, bad breath, exposed roots of the teeth, and eventually tooth loss results. The inability to properly chew food affects our ability to maximize our nutrition.

Currently, we know that bacteria from gum disease and infection from rotten teeth can get into a patient’s bloodstream and cause heart problems. Chronic gum infection in a pregnant woman can lead to premature birth; I have referred patients to their physicians for screening for diabetes based on my observation of their early onset of infection and difficulty treating their gum disease. Healing can be slowed if the patient is an undiagnosed diabetic, and control of diabetes is sometimes enhanced and easier when there is decreased infection in the body.

A young child in Washington, DC, lost his life when the abscess from his tooth precipitated a brain abscess and led to his untimely death. Death from a rotten tooth is a horrible way to go and could have been easily prevented.

If you paid extra money for four preventive visits to the dentist per year, most of your major dental problems would be detected early, and they would be less costly. There are times when worn teeth will need to be crowned—another way of replacing worn enamel.

You may choose to improve the function and concurrently improve the looks of your teeth.

Large nerves run directly from the oral structure to the brain without traveling through the spinal cord. They are so sensitive that you can detect a strand of hair in your mouth or a small fishbone. Children use their mouths to interact with things they come in contact with; it is one way they explore the world. When you are stressed, it even manifests in your oral structures.

In the coming years, DNA will provide clues about those who are more susceptible to oral and other diseases. Currently, dental offices provide screening for oral cancer, high blood pressure, diabetes, and other physical ailments. There are even in-office tests for the presence of harmful bacteria and inflammation in your body that can help guide your dentist in determining the best treatment for you. Nutritional awareness and training have been a part of the dental curriculum and will assume more importance as more research became available. The best is yet to come from dentistry.

In 1840, the first dental college in the world was founded in Baltimore, Maryland. The Baltimore College of Dental Surgery University of Maryland Dental School was formed because of Horace Hayden and Chapin Harris’s two men’s vision. Hayden and Harris were unsuccessful in convincing the medical school to train dental specialists, as some of their counterparts in Europe, so they took the matter to the legislature. The Maryland state legislature persisted, voted to allow the dental school’s formation, and dentistry became an independent profession.