“What Does My Insurance Cover?” An Inside Look at Dental Insurance Benefits

  • By StarBrite Dental
  • 03 Sep, 2015

Over the last few decades, the system of administration and payment for dental care has gone through a dramatic change. If this change meant that each person received better care and had better oral health, then all would be good. But it does not mean that.

What it does mean isn’t so easy to discover, so we’re going to explain. In this article, we’ll give you a behind-the-scenes look at your insurance benefits.

The Family Health Care Practice

Fifty years ago, a family might choose a dentist based on conversations with friends and neighbors. “Dr. Williams is so gentle, my children are never afraid of him,” says one mother. One man tells another, “His office is so efficient. They had me in and out in an hour and I never felt any pain.”

As the years passed, the family was happy with their care so they stayed with this dentist and paid his bills directly. The doctor was motivated to make the parents happy so they would keep coming back. Thus, he focused on great service and results.

This system is called “fee-for-service.” In this system, health care providers are paid directly by their patients for treatment.

This was the original system of health care in America.

PPOs Begin to Change the Landscape

With the rise of PPOs or “preferred provider organizations” built by insurance companies, all this began to change.

In a PPO, an insurance company makes a financial arrangement with medical providers such as dentists, hospitals and doctors to create a network of “preferred providers.” This insurance company then dictates what types of treatment they will pay for and how much the doctors are allowed to charge for them.

Dentists participating in PPOs are often limited in the care they’re able to provide. When they agree to be a “participating provider” with that insurance company, they have to accept a specific payment schedule and limitations on treatment.

Insurance companies saw this as beneficial, because it allowed them to put health care practitioners under contract to provide treatment at a discount. Employers signed up with these insurance companies so they could offer benefits to their employees, thus enabling them to recruit and retain better staff.

Gradually, it became the norm for many Americans to obtain their dental and medical care through a PPO.

Tough Treatment Decisions

All was not well, though. Certain unintended consequences resulted from the growth of the PPO model. While some of these were minor, some had major effects on the quality of treatment doctors were able to offer.

In the PPO model, insurance companies agreed to send a steady flow of patients to doctors participating in their network. As a result of this, they became an important source of income for doctors. Doctors began making business and treatment decisions around the insurance company policies.

For example, insurance companies might choose only to cover specific types of treatments or limit the amount of care that can be received in a particular year. As a result of this, a doctor might opt to go with one type of treatment instead of another, because he knew it would be covered by the patient’s insurance. This created a situation where both the patient and doctor began to make treatment decisions influenced by what insurance would cover—not strictly what was the best practice of medicine.

On the flip side, however, what if the patient needed or wanted care that wasn’t strictly covered by his insurance? What then?

In these situation, the patient often wound up paying the monthly premium for insurance PLUS the deductible, copay and additional treatment he needed. In this situation, the PPO model became more expensive for the patient.

By way of a real-world example, some forms of insurance might not cover a root canal, but will cover an extraction of the tooth. Though it would be medically better to get a root canal, the patient might decide to opt for the extraction because it’s covered by his insurance. In this scenario, he would needlessly lose a tooth and probably create further dental problems later in life.

This is an example of how what’s covered by insurance doesn’t align with the best medical treatment for the patient.

Compromised Quality

There are further problems that can arise in this system. When you are seeing a dentist in your insurance network, they may have business and financial concerns connected to maintaining their relationship with the insurance company. Like everyone else, they run a business and have to consider their bottom line.

As they’ve already discounted their fees to obtain a contract with that insurance company, they’re now dependent on that patient pool. Additionally, since some insurance companies have not raised the fees they pay to dental practices in a decade, some practices have to reduce the quality of materials they use in their patients’ mouths so they can stay profitable.

A highly scrupulous dentist will not compromise his dental services but then he may struggle financially. As a result, he may be less able to hire the staff he needs to provide fast, top-notch customer service.

Fee-For-Service: The Solution to Getting Great Care

Individuals who want the best possible care for their oral health often make the choice to visit fee-for-service dentists. These dentists are concerned with one thing: providing excellent care to their patients.

A “fee-for-service” dentist is one who is paid directly by his patients—continuing the same model that American health care practices were built on.

Because fee-for-service dentists receive fees directly from patients, their decision aren’t likely to influenced by insurance company policies. Likewise, they have no financial incentive to use sub-quality materials or procedures, because they don’t have to adhere to rates and treatment plans developed by PPO administrators.

Insurance Will Still Cover Fee-For-Service Treatment

Keep in mind that patients can still use their insurance in fee-for-service practices. The practice will submit their insurance for them as usual. The major difference is that the insurance company reimburses the patient directly and the patient pays the dentist. The patient pays rates based on that practice’s fee schedule and the insurance company reimburses the patient whatever portion of this is covered by their policies and regulations.

StarBrite Dental has always been a fee-for-service practice. We want you to come back to us because we have given you the exact care you needed and the results you wanted. We will help you understand your treatment program and why it benefits you to receive those exact services.

We feel that this is the very best way to provide the best care – and we will never compromise our quality or materials. We are not contracted with insurance companies but, at the same time, know how to maximize your insurance benefits to the best advantage.

If you’re looking for a dental practice that is truly focused on your well-being, come talk to us. For new patients, we offer a Free Dental Consultation. Schedule your appointment for this consultation by calling   (301) 377-2186 . We serve patients from all over the Washington, D.C. area.

Our goal isn’t just to be a dentist—it’s to be a partner in your health and success.


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