Insurance is something ingrained in most of us as a necessity, a way to save money for the health services we need. It also protects us from the unexpected and ensures we can receive the highest quality of care by choosing the providers who care for our family and us. 

But what happens when you pay for insurance but don’t receive the highest quality of care? Or even worse – the provider you selected based on your plan cuts corners to ensure they can cover their costs?

Understanding insurance shouldn’t be an enigma. Learn the ins and outs of insurance and why more people choose to go out of network for their dental care.

Demystifying in-network versus out-of-network

When someone chooses to go to an in-network provider, they submit a claim for a contracted amount for the services rendered. If they go out of network, there isn’t a contracted rate. If the cost for services rendered is higher than what their insurance will pay, any extra amount due is the patient’s responsibility. Does this mean a dentist can charge anything they want for services? Well, yes, but it isn’t intelligent. The standard is to base charges on a usual and customary rate. This rate is calculated by comparing rates to all dental offices in Oregon. At Living Dental Health, we review this information annually and adjust our rates based on the 80th percentile to ensure our fees are fair for the state.

Insurance is not there to keep you healthy. 

Insurance carriers are denying more medically necessary treatments than ever before. This leaves patients having to pay out of pocket for services they need or electing to have inferior treatments covered by their plan. A typical example we see is when a patient needs to have a dental cleaning every four months, but their insurance only covers cleanings every six months. It should be up to the patient to make the decision, not the insurance provider. 

Claims processing is often left to unqualified personnel.

Due to COVID, more claims are outsourced to people working from home. In some cases, a college student between classes or someone in India may be deciding if a claim should be covered. The people reviewing these claims are not qualified to determine what is medically necessary and what isn’t. But they do because that is their job. This means dental offices are having to go through multiple appeal processes to get things approved. And despite these efforts, some treatments are never approved. 

Cheaper isn’t always better. 

A low-cost insurance plan may sound like a good idea but keep in mind that these plans reimburse dentists at a lower level. Corners are cut to offset the loss in reimbursement. Often this means dentists have to make the difficult decision to use more inferior quality products in services and treatments. 

For example, a crown should last 10-20 years before needing to be replaced. If lower quality products are used, they are more prone to cracking in the material used, which would require replacement, often within a year or two. But insurance has something called a “replacement period,” which means they will cover the same services after a certain period – usually 5-7 years after the initial treatment. Guess who has to pay for the replacement? The patient. 

The fine print.

When verifying eligibility, dental offices are provided a summary of your coverage benefits. From this information, the dentist can estimate what will be covered and at what cost. This can be very confusing for patients. Here’s why: say Sally needs to have a dental filling, and for safety reasons, her dentist recommends composite instead of silver (amalgam) fillings, which contain about 50% mercury. Sally knows that her plan covers fillings at 80%. But the fine print – which her dentist doesn’t receive – says that only silver fillings are covered at 80%. Composite is covered at 50%. Dental summaries don’t provide the finer details to show any downgrades of material. Only the patient has access to the entire plan. This disconnect creates a trust issue between the dentist and the patient. It is up to the patient to understand their plan. We recommend always getting a predetermination before an extensive treatment. While it is not a guarantee of payment, it does indicate what the plan will pay. 

Closing Thoughts

At Living Dental Health, we don’t compromise patient care due to insurance restrictions. We no longer contract with some of the worst offenders and now offer an in-office savings plan. Our plan takes the guesswork out of treatment planning and provides patients with peace of mind – knowing they are getting the best treatment for their condition without fear of replacement clauses or plan exclusions. Don’t compromise your care. Your teeth and your wallet depend on it.

Living Dental Health