Everything you need to know about dental insurance

"Do you accept insurance?"

 

It’s one of the most common questions I get from patients, and I think it’s in your best interest to understand the history and complexity of dental “insurance” prior to making a decision on where and how you receive dental care.

 

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First off, let's confirm the goals you have with your smile.

 

It’s important that we first agree that we share the same 4 goals. These goals are as follows:

1. We want your time spent at the dentist to be focused on preventive care for you and your whole family to maintain your optimal oral health for a lifetime. We do not want "surprise" cracks, cavities, and problems diagnosed at each visit.

2. In the case that you do have active dental disease (cracked teeth, cavities, gum disease, etc), we will stabilize these concerns first with the most appropriate therapy, and then we would proceed with a diagnostic work up to discover and address the root causes of this disease and prevent this from happening again in the future.

3. We want to use the most advanced technologies, the best materials and therapeutics, and to be treated by the most qualified team members to ensure you receive the best clinical outcomes.

4. We want to make this highest standard of care as affordable as possible.

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Long story, short, the answer is no. Puerto Rican dental insurance companies do not allow me to accept dental insurance. 

Puerto Rican dental insurance companies do not allow me to accept dental insurance without also allowing them the control to make decisions on the types of materials I can use for treatment, the frequency of which I recommend patients to have various diagnostic and therapeutic procedures, among other compromises to the quality of care I deliver to my patients. So as much as I would like to accept dental insurance to facilitate access to care, I can't do so while also maintaining the same standard of care for my patients. However, I am doing my best to provide alternatives to dental insurance to make your care more affordable.

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For those more interested in the details of the why behind this, I have provided a thorough explanation below. I spent countless hours reviewing and interviewing local dental insurance providers, and none of them allowed me to satisfy all 4 promises above. 

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What is dental "insurance" & where did it come from?

Insurance is intended to protect us from catastrophic loss. If your home is destroyed, homeowners insurance may allow you to rebuild. Medical insurance will pay for an emergency appendectomy or a heart bypass. The risk of buying insurance is determined by you proving detailed information about what is being insured. You determine your risk, that risk is calculated, and a premium is charged.

On the other hand, dental “insurance” does not inquire about your current state of health but instead provides a “one size fits all”approach to coverage. You are not asked about your dental history or current state of health. Yearly benefit limits in dental insurance have no relationship to the condition of your mouth but exist only to limit costs to the employer or provider of the insurance. As a result, dental insurance is not really insurance, but simply pre-paid specific benefit that has no relationship to your own state of dental health or disease.

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Unlike medical insurance, which started being offered in 1850 by the Franklin Health Insurance Company of Massachusetts, dental insurance is a fairly recent phenomenon when it was first introduced in the 1950s in California and quickly rose in popularity as a way for corporations to attract new workers. By the 1970’s, these plans were widely available and usually provided a maximum annual coverage of about $1000 (which is still the maximum today for most plans). The first plans didn’t distinguish between in-network and out-of-network providers. They simply established usual and customary rates for the area and would pay (typically) 100% of preventative care, 80% of minor dental work (such as fillings), and 50% of major work (like crowns, bridges, etc).

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Today with the advent of PPO, the dental insurance landscape has drastically changed.  Dental insurance companies are owned by stockholders, equity firms, and investment bankers for the purpose of making money.  Unlike medical insurance companies that can run into unlimited liabilities with large claims, dental insurance has a cap on the coverage, and that cap has barely changed since the 1970s. As a frame of reference, in 1970, the cost of an average new car was $3,542. The average price today is $33,560; if dental insurance would have kept up with their annual maximums, today they would cover up to $10,000 a year, but most plans still cap at $1,000/year.

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Bottom line dental insurance is a very lucrative business.  If they want to make more money, the company owners decide to reduce their coverage by limiting the coverage on care you can receive without considering the consequences to the patient, and they certainly aren’t prioritizing decisions based on how to optimize for your longterm health and wellness. Also, it is not uncommon to have dental insurance companies altar the dentist’s treatment plan. As they continue to lower payouts and deny claims, dentists are dropping out of the networks because they are uncomfortable with the care dictated by the insurance companies, and these doctors are unable to use the most advanced technology, the best materials, and hire the most qualified clinicians on these reduced fees. 

 

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Why can’t Dr. Beth accept PR dental insurance?

 

(1) The patient can’t choose which doctor they see; instead, that’s dictated by the dental insurance company.

The patient-doctor relationship is critically important for any patient, but it becomes increasingly more important for children, for patients with a prior history of dental trauma or who experience dental anxiety, or patients who have complicated medical histories. So not being able to choose which doctor you want to see for your care management and treatment is a pretty big non-starter.  

 

In the US, when a patient does not want to see the doctors who are “in-network” with their insurance company, they still have the option to choose their preferred doctor (who may be out of network) and pay the difference in whatever the insurance company does not cover. Unfortunately in PR, that is not allowed; it is unique to PR where you are limited to using your benefits only with the providers who have signed up with your particular insurance company.

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(2) Preventive care is controlled by insurance companies, and their restrictions on coverage can be detrimental to your health.

Although experts agree that routine dental exams and regular cleanings may help prevent the incidence of higher-cost treatments such as periodontal surgery, root canals, extractions, and fillings and early detection and prevention can minimize your need for more serious dental treatment, insurance companies continue to reduce coverage on those services.  First, they restrict the number of visits you may need to control gum disease.  Some people who have the genetics and lifestyle that contribute to gum disease need to be monitored more closely.  Regardless, insurance companies will only cover a fixed number of visits for gum therapy.  Some limit the visits to as few as one covered appointment per year and restrict some test and x-rays necessary to monitor your progress to once every 5 years. Gum disease has been found to have a correlation with heart attacks and early onset of Alzheimers. It is not in the patient’s best interest to have these restrictions.

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Secondly, although with the new digital x-rays patients get 1/20th the radiation from an x-ray, insurance coverage refuse to pay for many x-rays that are necessary for the dentist to monitor your dental health.  If something goes undetected until it causes pain, inconvenience, or even loss of teeth, it doesn’t matter to the insurance company.  Remember, a patient subscriber with their plan will only cost them a maximum of $1,000 per year.

 

(3) Best care options are frequently denied.

Many times when your dentist is designing a care plan for you, she might like to consider optimal care that would include treatments that the insurance company refuses to cover. Your choice is to do what is best and the insurance company pays nothing or except the care that is covered at 50% or less and live with the inconvenience of coping with less than optimal solutions. I have patients who live with a piece of plastic in their mouths, catching food, causing mouth odor and promoting more dental disease because that was all the insurance company would cover.

 

(4) Dental insurance companies do NOT stay up-to-date on scientific research and evidence-based clinical care, meaning you could be exposed to materials that puts your health at risk.

Dental insurance companies encourage doctors to use fluoride despite its documented neurotoxic effects and the very clear, better alternative in use of dental hygiene products with hydroxyapatite. Additionally, they can end up dictating a doctor’s treatment plan by reimbursing only when silver mercury amalgam fillings are placed and deny coverage if the doctor wants to use a more expensive, but less toxic tooth-colored filling. These are just two examples of these compromises in care decisions, but they reflect how outdated these companies are and how clear it is that they do not care about optimizing a patient’s clinical outcome and their longterm health.

 

(5) Correcting pre-existing conditions is frequently not covered.

Although dental insurance companies claim to cover major reconstructive dental care like removable partial dentures, dentures, bridges and implants to replace missing teeth.  Be aware of the small clause “pre-existing conditions”.  What this means is if a tooth was missing prior to you being covered the insurance company will NOT pay claims on replacing them. I have had many patients disappointed because they had dreams and aspirations that dental insurance companies would help them finally restore their confidence and a healthy smile, only to find out they had not read the “pre-existing condition” clause.

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(6) Waiting periods can jeopardize your health.

Many insurance companies have waiting periods before they will cover certain dental procedures.  This creates an inconvenience minimally or can actually be detrimental to your health if you are encouraged to wait until your care is covered. This becomes very concerning when a small cavity can be stabilized with a small filling, but because the patient waits, the cavity grows larger, and now the tooth requires a crown or something worse, like the tooth gets infected and causes a major risk to the patients overall health. Waiting periods promote health risks and bigger problems.

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(7) The reimbursement rates are equivalent to dentists’ fees from the 1980’s, making it impossible to spend the appropriate time for procedures, to hire the most qualified team members, and to use the best materials.

One of the “top” insurance plans in PR reimburses a doctor at the following rates: Comprehensive new patient exam: $22, Digital health scan: $0, Diagnostic Records: $0. I spend over an hour with each of my new patients to have a thorough history and exam and to take complete records to allow for a thorough analysis of your health and complete discussion of recommendations and questions. I’ve spent thousands of hours in continuing education courses and hundreds more training other doctors and clinical team members on best practices; all of this to stay on the forefront of the highest quality of care for my patients. It would be impossible to deliver this quality of service if I was restricted to the fees dictated by these insurance companies.

 

(8) Many dental insurance companies create a paperwork barrier to processing your claim.

Supposedly lost coverage requests and Insurance claim denials are a standard operating procedure with most dental insurance companies. It is called “stall as long as you can”.  There are only two things that can happen with that game.  The dentist gives up on collecting the money he earned and cuts his losses.  Or the insurance company gets to keep his earned money a little longer to invest it somewhere else.  When a claim is denied or ignored, it is not uncommon for a dental employee to be left on-hold for over 30 minutes.  If a dental office has 16 unpaid claims you can see the dentist will have to hire someone full time to do nothing but listen to elevator music while trying to recover the money the office has already worked for. Some dental offices have a policy that if they don’t get paid by the insurance company within 60 days you will pay and join them in the fight to get your insurance benefit back. 

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(9) Orthodontics is rarely covered or slightly covered.

Although experts know that crooked teeth not only cause psychological and social problems, crooked teeth promote dental disease including cracked and broken teeth, gum disease, and TMJ pain. Many insurance companies dodge the correction of crooked teeth with the pre-existing conditions clause.  Those companies that do cover that correction sometimes pay benefits as low as 20% of the fees, leaving you with the rest.  You will be disappointed if you depend on your dental insurance to straighten your smile.

 

(10) Cosmetic care is never covered.

In today’s competitive world, jobs, opportunities and even romance can be affected by your smile and how you feel about it.  Insurance companies don’t care.  If you have multiple cavities on front teeth the solution they will pay for is white fillings.  Although white fillings are not bad, even the best white fillings microscopically look like sandpaper as compared to tooth enamel.  So imagine what happens when you eat cherry pie or have a glass of red wine.  Yep you’ve got it.  White fillings turn a light shade of pink.  Also I have seen white filling catch food between the teeth causing tooth decay on adjacent teeth.

Dental insurance companies almost unequivocally decline to pay for more comprehensive and aesthetic porcelain crowns. Patients who have let insurance companies influence their decision on accepting large white fillings up front come back later regretting their decision and then pay out of pocket for the better restorative decision.  Although they are much happier today, they paid a heavy price. They paid the deductible and co-pay for the fillings and then for the full coverage porcelain crowns. Plus they had to go through an extra dental procedure.

 

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What next? What are the alternatives?

 

Use Health Insurance:

While I can’t accept dental insurance, I am excited to report that I have been able to establish protocols and cooperatives with physicians such that part of your oral healthcare needs (specifically those that impact your whole-body health) can be covered by your medical insurance.

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Implement Free Educational Content Here on My Website: 

I will continue to offer for free via my website educational information related to preventive health so that you can implement best practices at home and reduce your time and money spent at the dentist. Remember, the vast majority of dental disease is preventable; you weren't just "born with bad teeth". But you have to do the work to maintain health!

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Affordable In-House Payment Plans & Alternative Financing Options: 

I try to make my fees as affordable as possible without compromising our 4 goals listed above, and I also offer payment plans and other patient financing.

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Disclaimer:

Let it be known that this explanation is by no means a criticism of any doctor or practice that does decide to accept insurance; it is meant to educate patients on how their dental insurance company does not have their best interest in mind at all. Typically, these are providers who are doing the best they can to increase access to care to as many people as possible by making it as affordable as possible. Unfortunately, this may mean that they have assistants doing the work of what hygienists normally do, or patients do not get their comprehensive oral health checked as often or as thoroughly as would be advised, or that these clinicians are forced to use less advanced techniques or materials, but they’re doing the best they can under the restrictions that the insurance companies have put into place.

 

Author Credit:

Much of the copy and examples referenced on this page was originally researched and written by Dr. Bryce Gates of McKinney, TX, who graciously allowed me to use his hard work and excellent explanation of these issues to help educate more patients on how to make the best decisions on behalf of themselves and their families. Thank you, Dr. Gates!