Just do what my insurance pays for!

Patients will sometimes balk at treatment not covered by their dental insurance.

Patients will sometimes balk at treatment not covered by their dental insurance. Staff people frequently hear, “Just do what my insurance pays for. I don’t want anything extra!”

Some consultants advise dentists to stop dealing with dental insurance. Others advise offices to “just say no” when it comes to helping patients understand the limited nature of dental benefits. Since it is the “patient’s plan,” it is not the dentist’s or staff’s responsibility to explain how insurance works. Theoretically, this is true. However, many dentists rely on their indemnity insurance patients as a stable base for their practices. In fact, a recent ADA poll showed that a lack of insurance was the No. 1 reason most patients gave for not visiting a dentist.

If you are a dentist with more patients than you can handle - or if you currently require patients to deal with insurance on their own - this column is not for you. If you are a dentist who has patients who want their insurance to pay the maximum (whether or not you file claims for them) or if you are a dentist who would like to help patients accept and pay for the treatment you are recommending, these excerpts from one of my patient brochures might help.

Why doesn’t my insurance cover all the costs for my dental treatment?

Dental insurance isn’t really insurance (defined as a payment to cover the cost of a loss) at all. It is a monetary benefit, typically provided by an employer, to help their employees pay for routine dental treatment. Most plans are only designed to cover a portion of the total cost.

But my plan says that my exams and other procedures are covered 100 percent!

That 100 percent is usually what the insurance carrier allows as payment toward a procedure, not what your dentist or any other dentist in your area may actually charge. The allowed payments are sometimes referred to as UCR or “usual, customary, and reasonable” charges. However, UCR more typically represents a list of payment amounts negotiated between your employer and the insurance company. An employer usually selects a plan with a list of payments that corresponds to its desired premium cost per month. Therefore, there usually will be a portion not covered by your benefit plan.

If I always have to pay out-of-pocket, what good is my insurance?

Even a benefit that does not cover a large portion of the cost of what you need pays something. Any amount that reduces your out-of-pocket expense helps.

Why is there an annual maximum on what my plan will pay?

Maximums limit what a carrier has to cover each year. Dental plans are different from medical plans, in that dentistry is needed frequently. Medical emergencies are rare. It is your dentist’s responsibility to recommend what you need. It is the insurance carrier’s job to control payments.

If my insurance won’t pay for this treatment, why should I have it done?

It is a mistake to let benefits be your sole consideration when you make decisions about dental treatment. People who have lost their teeth often say that they would pay any amount of money to get them back. Your smile, facial attractiveness, ability to chew and enjoy food, and general sense of well-being are dependent upon your teeth.

What should I do if my insurance doesn’t pay for treatment I think should be covered?

As your dentist, I do not have the power to make your plan pay. If your insurance doesn’t pay, you are responsible for the total cost of treatment. Sometimes a plan will pay if patients send in claims for themselves, or if the Employee Benefits Coordinator where patients work steps in. We can give you copies of what you need.

Dental insurance issues are really the patient’s problem. However, many dentists keep their patients happy and accepting new treatment by providing assistance with their benefits. There is a way to help, but it doesn’t include taking on the total responsibility.

Carol Tekavec, CDA, RDH, is the author of the “Dental Insurance Coding Handbook-CDT 2005.” She is the designer of a dental chart, and is a lecturer with the ADA Seminar Series. Contact her by phone at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com, where you may also locate her patient brochure, “My Insurance Covers This ... Right?”.

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