The Good, the Bad and the Ugly
by Kristina Mackie, DDS
Loretto Family Dentistry, PLLC
Most of the patients in my practice carry dental insurance. The insurances my office currently accepts are strictly PPOs (Preferred Provider Organization) that provide a yearly maximum benefit of typically $1,500-$2,500 annually. One interesting fact about this number is it hasn’t changed since the late 1970’s. If it had, most policyholders would have approximately $10,000 to work with annually. What this means is the insurance company will pay up to the maximum benefit amount on the policy holder’s behalf per year. After this number is reached, services are no longer covered and must be paid out-of-pocket until the renewal date. Policies often carry a deductible; the amount the insured must pay out-of-pocket in order for the insurance benefits to kick in. Preventive services such as basic cleanings, exams, radiographs, sealants, and fluoride are usually covered at 100%.
There are restrictions on how often these services can be rendered and policies can vary from plan to plan. Most other services like fillings, crowns, root canals, and extractions are covered at a percentage.
It’s important to note that in cases where services are denied or not covered, this does not mean the services are not beneficial or necessary. Remember, most dentists are in the service of trying to help their patients achieve optimal dental health. Insurances care little about this and are a profit-driven, billion-dollar industry for a reason.
Through the multitude of confusing frequency clauses, waiting periods, and covered and non-covered services, it is important to note that having insurance can help lower your out-of-pocket expenses for dental services when compared to not having insurance and seeking the same treatment, even after you’ve maxed out of benefits. This is because you are still eligible for the lower negotiated rates within the contract.
Remember, the patient, as a client of the insurance company, wields more power with representation governing their policy than the office staff does on their behalf. Most all dental offices accept dental insurances as a service to their patients. Working with dental insurance companies is oftentimes tedious, frustrating, and requires increased expenses for the practice in lower reimbursement rates, claim denials and payment delays, and manpower leading to increased payroll costs.
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