Many people across the US compare the costs of buying dental insurance for their family dental needs from major insurance companies to merely paying out of pocket.
The following gives a brief summary of the benefits of most plans, and discusses their advantages and negatives.
Most family dental insurance plans excel when looking at most preventative and basic services. Dental insurance companies categorize normal prophies (cleanings), fluoride treatments, sealants, xrays, and exams as basic treatments, and cover these usually 100%.
In or out of network, 98% of the time, you’re going to be covered 100 percent on these basic items.
Basic services usually include fillings, extractions, deep cleanings which under a standard 100/80/50 plan is covered at 80 percent.
Again, either in or out of network, usually you’re going to be covered 80% after deductible.
More expensive services including crowns, bridges, implants, dentures, partial dentures are covered at 50% after deductible.
Most plans pay the usual 100/80/50% breakdown whether you opt for an in-network or out-of-network dentist. Some plans (sadly most of the Humana and United Concordia, and probably 50% of the United Healthcare plans) unilaterally decide that they don’t care what a dentist charges, they are only going to pay on some nonsense super low fee schedule, which barely covers staff and supply costs in the office. Humana and United Concordia are the worst offenders, in that they tend to deny even the most basic services as being unnecessary (for instance simple diagnostic periapical x-rays are being denied unless the dentist hand writes a reasoning narrative for a 7 dollar xray). Obviously their goal is to require so much paperwork that most dentist will simply give up and just charge the patient.
PPO in network vs out of network: our office is in network with some insurance companies and out of network with some. Here is the truth: most insurance companies have the largest buildings in town, if you look at some of the most beautiful buildings on GW Bush turnpike in DFW, you’ll notice that many of them have large insurance company names on them. This is because they tend to pay out a lot less than they take in via premiums (the money your employer or you pay in). I (the owner), just looked into the last year’s statement by Delta Dental: they averaged 470 dollars per insured yearly premium, and averaged 240 dollars paid out per insured to the dentist. As you can see they are keeping nearly 50 cents on the dollar. And you wonder why the Giants play in “Metlife Stadium” at a cost of 400 million dollars over 20 years. Yeah, those are your premium dollars at work.
To save money, the insurance companies try to tempt family dentists into signing up for their plan as an in network provider, and in exchange, promise to direct patients to their offices. This is where things get sticky: the in-network family dentist has to accept around a 50 percent reduction in pay for the patients who are in network.
So how does this add up? Well, what happens is that every deep filling gets converted from a 90 dollar in network 2 surface filling into a 1,850.00 dollar root canal build up and crown. You see, the doctor doesn’t make almost any money after costs on the 90 dollar filling, but definitely makes money on a 1,850 dollar root canal and crown. You see, forcing a doc to choose between losing money on a filling and making money on an “upgraded” treatment is really tempting him to be unethical. Likewise, the dentist might choose to make a resin flipper with a wire clasp vs. a cast metal frame-work partial denture (a far superior product), merely because the lab fee on the flipper is 150 dollars vs. a 400 dollar lab bill on the partial with the cast metal framework. Insurance companies pay around 650 for the cheap partial vs. 750 for the good one. The in network dentist makes 150.00 dollars more recommending the inferior product to the patient.
Insurance companies are trying to train the dentist to recommend the cheaper and inferior product. All they care about is how tall of a skyscraper they can build, not how well your teeth feel, look and function.
We at North Garland Dental Implants and Orthodontics have resisted this, by staying out of network with nearly every insurance company. The ones we have contracted with have pursued up, offering us 95% of our normal fees to sign us up. Insurance reps wait in our waiting room to negotiate with us. This is basically unheard of in DFW where the average discount is 40-50% off usual and customary fees (UCR).
Our out of network insurance companies send us no patients. We rely on word of mouth, and stellar google and other online reviews for new patients. We charge enough for our fillings, such that our doctors can honestly give you our recommendations without worrying about losing money if they choose the ethical option.
Our goal is your improved oral health, and we will never allow an insurance company’s fee schedule to dictate treatment.