Humble Dentist Reveals 5 Dirty Little Secrets About Your Dental Insurance and What You Can Do About It!
So What’s the Deal With Dental Insurance?
As a dentist in Humble, TX, you would expect the first thing someone would ask us is, “What kinds of dental implants, cosmetic dentist, periodontist, oral surgeon treatments do you offer?” or maybe, “When is your first available appointment?” However, more often than not, the first question we get asked by new patients is, “Do you take my insurance?”
Dental insurance, like medical insurance, is complicated and can be a stressful matter for patients who have a hard time sifting through the fine print on their policies and getting straight answers from their insurance companies by phone. For this reason, our staff is here to help you answer questions and to get you the most cost effective dental care possible.
I put together the following article to help clear up a lot of the confusion regarding dental insurance. Share with family and friends and let’s work together to make dental insurance less confusing!
Answering Your Questions on a Complicated Topic
Those of us with dental insurance coverage are instructed to seek out “dentists who take the insurance plan” to receive the least expensive dental care possible. It’s smart to save money where we can and it’s smart to try to utilize dental insurance that we pay yearly premiums for. There’s a lot about dental insurance companies, however, that we as patients are unaware of. Every insurance plan is different and we are happy to answer questions regarding your particular plan. The following are generalities that will hold true for many dental insurances. Here’s some information you may not have heard before:
I. HMO versus PPO:
Insurance plans are divided into either dental HMOs or dental PPOs. Discount plans aren’t true “insurance” and offer blanket discount on services for dentists who sign up, like honoring a coupon. If you have a DHMO plan, your insurance will only pay for a selected dentist to perform services. These dentists typically get reimbursed yearly for every patient that is assigned to them (For instance, the DHMO dentist has 4,000 patients on their list and gets paid so many dollars a year for each of those patients regardless of how much or how little work that dentist does for those people). This is a financial incentive for these dentists to do as little work as possible for each one of these patients. This doesn’t mean these dentists are necessarily bad dentists, just that the less work they do per patient, the more money they make. If this makes you, as a patient, uncomfortable, then you are not alone.
Dental PPOs (or DPPOs) work differently. Dentists are divided into two main categories, “in-network” and “out-of-network”. Patients have a choice who to see. Dental patients are urged to see “in-network” dentists to get the least expensive dental care possible. Dentists who sign up with DPPOs are contracted with those insurance companies to only charge a certain fee for each service they offer. Dentists who are “out-of-network” can choose what they charge for a service.
“In-network” dentists are listed online and in patient insurance manuals and receive “free advertising” for new patients. In exchange for that free advertising, these “in-network” dentists get paid less than market value for the services they provide. In many cases, the amount that “in-network” dentists get paid by the insurance companies is less than half of market value and isn’t enough to even cover the cost of materials that are ideal in providing that dental service (for example, an “in-network” dentist may get paid $300 for an anterior crown when the lab fee alone to make that crown may cost $500, resulting in the dentist not getting paid anything for their time or office overhead and the dentist actually paying out of pocket $200 to get the patient the quality of crown they should have). This would have the effect of forcing your Humble Tx dentist, in this example, to seek out less expensive (cheaper) materials that are not necessarily long-lasting, aesthetic, or cleansable as they would have hoped to provide if they were not an “in-network” dentist. Many patients don’t realize that their choosing an “in-network” dental provider may mean they are getting cheap dentistry done.
II. “In-network” versus “Out-of-network
In many cases, the money patients receive as payment for services from insurance companies is the same for “out-of-network” dentists as it is for “in-network” dentists. For instance, if your insurance plan has a $1000/year benefit, you will likely get a $1000 benefits whether you use an “in-network” or “out-of-network” dentist. “Out-of-network” dentists are free to use the materials and dental labs that are ideal for each service without being constrained by contract terms with dental insurance companies.
III. Doesn’t my dental insurance cover what I need?
Each plan will have a listed set of procedures that are either “possibly covered” or “never covered”. (Note: Dental Insurance calls “possibly covered” procedures “covered” but we know better.) If your dentist diagnoses a need for a service that is “never covered”, your insurance company will not even consider whether or not they think you need the service; they will always deny it.
In other words, if you grind your teeth and need a retainer at night to keep you from breaking teeth in your sleep, and your insurance lists retainers as “never covered”, they don’t care whether you need it or not. They won’t pay for it. Procedures that are “possibly covered” are usually listed in insurance manuals as “covered procedures”. More aptly named “possibly covered”, these are services that your insurance will review according to their regulations and decide whether they want to cover it or not.
For instance, let’s say you need a filling done for a cavity, and your insurance lists fillings as “covered” (or more accurately, “possibly covered”). Insurance has the right to say that they will pay for part of that filling but that they mandate it has to be a silver filling even though it’s going on your front tooth. (Yes, this happens.) Tooth-colored fillings are more expensive and if you opt not to have a silver front tooth, then your insurance may not cover that at all. Do you have hereditary bone loss and need cleanings four times a year instead of twice to prevent teeth from falling out? Unless you have had gum surgery in the last year (and it’s a goal not to have it more than once in a lifetime) then your insurance may not cover more than two cleanings a year. You get the idea. (By the way, there aren’t any “always covered” procedures. Sadly.)
IV. My dental insurance doesn’t pay 100% of my covered procedures?
PPO insurances almost always pay only a percentage of each covered procedure. Let’s walk through a scenario for a patient who has a dental PPO and needs a crown on a tooth that is broken. Once the tooth is repaired with a crown (and not beforehand), your Humble Tx dentist can submit a claim to the insurance company that says, “I did this crown to splint the tooth because the tooth was broken.” The dentist sends documentation in the form of clinical notes, x-rays, pictures, measurements. The insurance company reviews this information and accepts this as a covered benefit for the patient. That means the patient doesn’t owe anything for that crown, right? Nope.
The crown is covered at 80%. So that means that the crown that cost $1000 is now only $200 for the patient, right? Nope. This insurance only reimburses for the least expensive solution which is a metal crown which costs $500, of which they will pay 80%, or $400. The patient got a porcelain tooth-colored crown, which most of us would want. So that means that the patient will pay the residual $600 of the $1000 charge for a porcelain crown. Feeling discouraged? Your doctor deals with this nightmare daily to get you the best coverage they can and there’s not a thing your doctor or you can do about it.
V. Shouldn’t my doctor have known beforehand that my insurance wouldn’t pay for this procedure?
Most insurance companies provide limited information to dentists before claims are made. All the dentist knows in most cases is what category the treatment falls into (either “possibly covered” or “never covered”). Even when dentists send a document to insurance companies before any treatment is rendered (called a “Predetermination of Benefits”), this document is no guarantee that insurance will accept the treatment (and even states so on the document itself, rendering it a veritable total waste of time unless it’s a required hoop to jump through for your policy in order to get claims through).
Just to determine what category your treatment falls into (“possibly covered” versus “never covered”) your dentist’s staff has to wait nearly an hour in many cases on hold on the phone with a representative. This process is done before your dental appointment so know that when you arrive for your new patient visit, we are excited to see you and have already spent the time to verify your potential benefits so you can make an informed choice in your dental care (or as informed as is possible based on limited information released by insurance companies).
What’s the bottom line? PPO or HMO or no insurance? “In-network” or “out-of-network”?
Unless you are comfortable with your providers being selected for you, stay away from dental HMO plans. If your company offers a dental PPO plan at a yearly premium that is far less than your annual benefits, that policy might be a good option (i.e. don’t buy a plan for $900/year that only has $800/year in benefits. Yes, this happens.).
Be aware that “in-network” providers will be working with a limited reimbursement rate and that may risk the quality of care you receive.
“Out-of-network” providers are able to provide services at reimbursement rates that they feel comfortable can cover quality materials and patients who seek care from “out-of-network” providers usually receive the same yearly benefits as if they were seeing “in-network providers”. In other words, if you get $1000/year in benefits, you get that $1000/year no matter whether you see a “preferred provider” or not.
What can I expect with Houston Dental Implants, Family Dentistry, Oral Surgery & Periodontics in Humble, Tx?
After years of working as an “in-network” or “preferred provider” for dental PPO plans, I grew frustrated in general with how it threatened to compromise the materials and quality of care I was offering. For instance, my payment from the insurance companies for a bone graft before placing implants became so low it didn’t even cover the cost of bone grafting material. Instead of going the direction of many providers and offering ground glass or other “filler” materials which are less effective and less expensive, I opted to become an “out-of-network” provider instead.
In my personal experience, because of this, I was able to maintain my integrity as a Humble Tx dental services provider and my enthusiasm for doing the best work I could. If I can’t treat every patient like I would treat my own family, then I don’t find a reason to get out of bed every morning and come to work.
To help make this as easy as possible for my patients, I do the following:
- I honor discounts for patients to make my costs for services competitive with “in-network” or “preferred providers” or “discount plan providers” while still offering the highest quality of care that is available in dentistry today.
- I file patient’s claims for them, manage communication, and fight for reimbursement for the patient just like I did when I was a “preferred provider”.
- And in most cases I gain reimbursement for patients that are just as much as the patient would have gotten if I were “in-network”.
Most of my patients have dental insurance plans and most of my patients receive their full benefits from those plans while still getting the care they deserve. Make sure you let me know if you have questions. Give me a call or click the “Make An Appointment” button on the right side of the page. I am Dr. Holly Gregory, the owner of Houston Dental Implants, Family Dentistry, Oral Surgery & Periodontics and I can’t wait to meet you!
The dentist at Houston Dental Implants, Family Dentistry, Oral Surgery & Periodontics now services dental patients in Humble, Atascocita and Kingwood Tx for an expanded range of dental services. These services now include cosmetic dentistry, pediatric dentistry, family dentistry, oral surgery and root canals. The addition of these services makes it so that almost any dental procedure you need can be done in one office, often in one day, without the need to be referred to another Humble dentist. Being referred to another dentist to have your dental work completed often increases your cost and always increases the time spent getting your dental issue resolved.
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Meet Dr. Gregory
Dr. Holly J. Gregory practices a full scope of periodontics with expertise ranging from dental implants to laser periodontal treatments, gum grafting, and Dr. Gregory can correct a wide variety of periodontal (gum) disease.
Our office is located at 19502 McKay Blvd., Suite 202, Humble, TX 77338. Call us today at (281) 446-9157.