Dental insurance is complex and hard to understand. Here we clear up insurance myths and explain the truth about dental insurance. And we help patients make insurance work to their benefit.
Wouldn’t it be great if we could all just call Bill Murray and his goofy group of comedians to put their “Insurance Myth Buster Packs” on and make us understand Dental Insurance? Perhaps in a movie that would work; but in the dental office, insurance is a bit more complicated.
Let’s address insurance company myths that cause confusion for our patients:
Myth: Insurance plan offers two free cleanings per year.
Truth: Insurance may not pay 100% of hygiene visits.
Most insurance companies state that they will cover two hygiene visits a year—either once every 6 months or twice a year, anytime.
But in small print, the plan document might say something like this: We will pay 100% of dental hygiene fees that we deem reasonable and customary.
So if your hygiene fee falls in the reasonable and customary range, the company will pay 100%. If the fee is outside this amount, insurance will pay a smaller percentage. Then the patient is responsible for the amount unpaid by insurance.
The policies small print may cause confusion for dental patients. Often insurance companies refuse to raise fees paid (even when increasing premium amounts). In fact, the largest dental carrier that covers South Carolina state employees still pays the same amount it paid in 1970.
Obviously, dental offices have raised fees since 1970. And patients want a thorough and complete exam rather than a “reduced fee exam.”
Myth: Reasonable and Customary is fee your dentist should charge.
Truth: Insurance company sets Reasonable and Customary fee for your employer to keep premium costs low.
The insurance company will negotiate an “allowable amount” or “usual and customary fee” with your employer. This will help determine the premium amounts that your employer pays.
This amount is usually less than what any dentist in your area charges. It is beneficial for the insurance company but not necessarily reasonable for dentists in your zip code area.
If your dentist’s fee is higher than the set fee, this does not mean your dentist is charging too much for a procedure. Instead, it indicates that the employer used low fees to negotiate lower premiums for your company plan. Or that the insurance company did not raise the reasonable amount for many years.
Your insurance company will apply the negotiated percentage for each procedure based on the employer contract.
Myth: Insurance will pay for all dental procedures outlined in the plan.
Truth: Your plan maximum may limit claims paid.
Your policy has a yearly maximum for dental payments. So as long as you still have enough of the maximum left for the year, insurance will pay. If you have used the maximum limit up on other dental procedures, insurance will not pay anything, or just pay what you have left of your maximum.
Sadly, insurance companies rarely raise the plan maximum. When companies began to purchase dental insurance in the 1960s, the standard limit was $1,000. That is equivalent to $10,000 in today’s dollars.
The typical maximum limit today is still $1,000 to $1,500.
Kathy has a link to most insurance plans. 
Real Time Eligibility details patient’s insurance benefits.
Myth: Dental insurance will cover emergency or large unexpected dental treatment.
Truth: Insurance will pay for emergency or large treatments only up to the yearly plan limit amount.
Unlike medical plans, dental plans will not cover large unexpected treatments, even in emergency situations. While medical insurance’s purpose is protecting you from large, unexpected health expenses due to a major sickness or emergency, dental insurance sticks to plan limits.
If you require extensive work in one year, your plan will not cover any amount over your plan maximum. In addition, the plan will pay only at the amount allowed for individual dental procedures.
The truth is that dental insurance is not meant to cover all care. Rather it will help you cover a stated portion of the costs of dental care.
View your dental plan as a yearly coupon for $1,000 (or $1,500, or your plan limit) against dental care costs. It is not designed to cover more than this limit amount.
Myth: I have to go to a dentist in my dental network.
Truth: The patient has the right to go to dentist of his choice.
You the patient have the right to choose what is in your best interest for dental care. It is important to go to a dentist who you trust. Investigate your dental insurance plan to make sure it gives patient choice.
Make sure you understand what type of plan you have:
- Non-network policies allow you to go to the provider of your choice, and will pay the same in or out of network.
- PPO (Preferred Provider Organization) policies allow you to go to the dentist of your choice. However, they have in network and out of network payment schedules. You may have to pay some out of pocket expenses if you prefer and out of network dentist.
- DMO (Dental Maintenance Organization) companies contract with certain dentists and require you to visit that office.
Every insurance policy has different rules and limits. 
Your insurance card gives only basic plan information.
Call the 800 number from your card or booklet to get this information for your plan.
Sometimes your dental cards or policy booklets will clearly outline what type of policy you have. But often this is not clearly stated.
Ask the plan representative these questions:
- Will my dental policy allow me to go to the provider of my choice?
- Is there a penalty for going outside of the network?
- If I choose to go outside of the network, how much will the penalty be?
Talk to your employer if your company plan does not allow you to choose your dentist based on what is right for you. Your company may be willing to reevaluate the plan it offers employees.
Myth: I can accumulate benefits that are not paid for future years.
Truth: Use dental insurance or lose dental insurance!
Dental insurance companies allow a certain amount each year for claim payments. Unlike Health Savings Accounts, these amounts do not carry forward to future years.
If you fail to use your benefits in a year, you lose this benefit.
Getting twice yearly dental check ups and cleanings are a huge benefit to dental insurance policy holders. And this preventive care may help prevent large, unexpected dental fees.
I like to work with patients to help maximize their dental insurance. Dental premiums are expensive. Please make sure to use your yearly dental benefits to save money-and to keep your teeth and gums healthy.
Kathy Haire, Cranford Dental Financial Coordinator
Myth: Dental insurance will pay for what is clinically necessary.
Truth: Your plan will pay based on payment frequency rules.
Your dental plan will state the rules for payment for dental procedures. The “clinically necessary” requirement of medical policies do not work for dental.
Each dental plan has pre-determined rules for what and when it will pay. Your reimbursement amount will be based on frequency, quantity, and reimbursement levels.
Dental insurance claim amounts are not intended to determine what services the dentist provides to a patient. Rather, they limit the insurance plan’s (and the employer’s) financial responsibility.
Myth: I should purchase insurance to cover my dental care.
Truth: Dental insurance is not always a good value.
Employer based plans tend to be more affordable than individual plans. And they offer a wider range of options and benefits. Patients usually save money on these plans because the employer works out the plan details and helps cover the premium costs.
If you are willing to do your homework, you may be able to find a decent individual plan that is somewhat affordable. But remember that insurance has to benefit the insurance companies.
Ask very specific questions before you purchase a plan:
What is the waiting period for benefits?
Insurance companies do not make the waiting period clear when you purchase the plan. You have to ask them, or read every bit of the fine print before you sign.
Some plans will make you wait from 6 months to 2 years before paying for non-hygiene dental treatment, even though you are paying your premiums monthly during this waiting period.
What are the total monthly premiums compared to the total benefits the plan will pay each year?
Compare the monthly premiums x 12 to your expected cost of dental treatment. The premium cost may exceed yearly dental care cost.
If you have healthy teeth and basically go to the dentist every 6 months for hygiene visits, then you may be paying more in premiums than you would pay for those two visits per year. Thus, dental insurance may not be a good value.
But if you know that you will need extensive dental treatment, you may be able to use dental insurance as a type of savings plan to pay for the treatment.
Dental Insurance and Cranford Dental in Rock Hill, SC
At Cranford Dental in Rock Hill, SC we work hard to maximize your dental benefits. We can make your dental insurance policy work for you while not compromising dental care.
Call 803-324-7670 or contact our office if you have questions about your dental insurance plan. Or if you have an outstanding claim that we submitted for you.
Our staff members do a great job working with patients to use insurance. Kathy Haire wrote this very helpful article explaining dental insurance benefits. Thank you, Kathy.
Dr. Elizabeth Cranford Robinson
At Cranford Dental in Rock Hill, SC, we believe that patients should get the ideal treatment for them based on what they really need. And that insurance companies should never determine the dentist they visit or the treatment the dentist prescribes.
Our patients often thank us for explaining how to get the best dentistry and how to get their dental insurance to assist them with payment.
Hopefully we can put the “Insurance Myth Buster Pack” away. Dental insurance is complex but very helpful if used correctly by the patient and the dentist.
We would be happy to work with you to maximize your insurance benefits.
Leave a Reply