Wednesday, December 17, 2014

Dental Insurance Part 2

Took a little bit longer than I anticipated to get to writing this second portion of the bit on insurance.  To rehash, the previous post covered the types of insurance, in-network versus out-of-network coverage and some other basic information.

Now I would like to touch a little on benefits.

Having a particular insurance doesn't mean it covers things the same as another plan on the coverage.  Your specific plan is usually dictated by your employer (if that is who the coverage is through).  Delta Dental, for example, has thousands of plans that are all different.  Sometimes the plans are different for people in the same household.  Many of the plans with Delta Dental are what is referred to as incentive plans.  With these plans, everyone will start out at a base percentage for most procedures and it goes up each year you use it until most procedures are covered at 100%.   If you neglect to use it one year, the coverage usually drops back to the starting level.  We love these plans as they work at keeping you in good shape by keeping you on track with appointments.  Patients sometimes hate having the out of pocket expenses the first 3-4 years of cleanings if they are used to having preventative covered at 100%, but come to love the plans when they don't have an cost to replace that old crown that popped off.

Another time that insurances have different benefits for those in the same family is for things that are age related.  Fluoride is one of the most important supplements we can have to let our teeth develop as strongly as possible.  Everyone who has enamel can benefit with a fluoride treatment.  Some insurances recognize that, but some will say that they will only pay for the benefit up to a certain age. Children are at higher risk of tooth decay because they typically have the worst diets and worst hygiene, but this isn't the case.  Its why insurances in general will pay more for fluoride and more frequent radiographs with children than with adults.

Another thing insurances do that can be tricky is downgrading procedures.  They will say that they will pay a certain percentage of a tooth colored filling or crown, but when the time comes to pay, they will sometimes change it up and downgrade the treatment to the lowest cost alternative treatment.  You may want a tooth colored filling on the front side of the tooth and they insurance company may say you can, but they will only pay the percentage for the silver filling.  This doesn't mean that you can't get the treatment that you want, but it means you will be responsible for the difference between the two types of treatment in addition to your copay.

Worst of all, your insurance company will sometimes request preauthorization for certain procedures and make you wait weeks until they let you know if they will or won't pay for it.  Sometimes they authorize treatment but the fine print says they don't guarantee benefits.

Insurance companies also like to just reject treatment all together, change their PO Box address so it takes longer for them to receive your claim, or request information that they don't typically need in order to keep from paying the claims in a timely manner.  Like any business they are out to make money (Delta Dental is technically a not for profit corporation, but that is more tax status and they make a pretty penny off of all of those insured and have the multimillion dollar CEO just like the rest of them).  If they can keep your money that your premiums paid for a little longer, they make more money off of it.

In short, if you feel like the insurance company is trying to pull the wool over your eyes, they probably are.  They have a number of tricks to make money.  When you are in our office, I like to say there are three people in the room.  Your dentist, you and your insurance.  Two of them care about your dental health.

We are typically very good at providing estimates on treatment and limiting surprises by doing benefit checks before your appointment and trying to preauthorize treatment whenever possible, but sometimes there is no predicting what they will do.  Some insurances won't pay for replacing tooth structure lost because of acid reflux, but will pay if you lost tooth structure by opening beer bottles with your teeth like crazy Uncle Cleatus.  It's maddening.  We are hear to help you understand.

Many insurance companies have great plans and many have really poor plans too.  If you are unhappy with the coverage of your plan, you employer can sometimes get a better one with the same company by just threatening to leave.

Hope this helps understand the mess the insurance industry is in.  It's getting worse with the ACA and government involvement.  Many of the plans through the exchange won't even tell us the benefits until after treatment is done and claims submitted.  It is unreal!

Everything should be as clear as mud now.