I don't pretend to understand dental insurance fully. There is so much variability with insurance plans that it boggles my mind. Fortunately, I have team members that help me decipher these plans.
Many people are able to maintain adequate oral health care that they would otherwise not if it weren't for their insurance plans. However, dental insurance does present many issues for the patients and the providers. Dental insurance issues is one of the greatest sources of frustration for patients and providers.
My greatest concern is that insurance will often dictate treatment. Yes, patients are ultimately responsible for making choices and the dentists are responsible to act in their best interest. However, insurance will play a major role in the decision making process.
Insurance premiums and coverage vary widely. Many of the contracts are not in the best interest of the patient. I may get the insurance industry angry with this statement, but it is a fact that they dictate treatment.
First of all, most insurance plans have a maximum benefit of $1000 dollars per year. Some of the better ones may have $1,500 or more per year. Back in 1967, the average coverage was $1,000 per year. It pretty much has gone unchanged. The kicker is that with inflation, there is significantly less coverage today. Premiums have also significantly increased since then. In otherwords, it costs the patient more for the insurance while getting less from it. What if the indicated treatment costs go well beyond these limits? The patient must decide to pay all of the fees over the limit or only have $1,000 of treatment performed while neglecting the rest. In this scenario, the indicated treatment will never be completed because things don't get better on their own. They obviously get much worse, more expensive, less predictable and less ideal. Their oral needs will never be met.
Another way treatment is dictated is that only certain procedures are covered. There are many clauses in the contracts that exclude even covered procedures. If a procedure is covered, in many cases, they may only cover 50% of the costs.
Provider choice can also be severely limited. Your dentist of choice may not be on their provider list. You will therefore have to either go to one on their list, or you may have to go out of network.
From the dentists perspective, some of the reimbursement rates are so low, that if they were to be in network, it would actually cost more to perform a procedure than to not do anything at all. This is precisely why so many dentists do not take certain insurances.
Many employers simply choose a plan for you. If given the opportunity to choose, review carefully what each plan offers. I know this can be an overwhelming and confusing endeavor. Fortunately, many dental offices have personnel that are very well versed in this area. Discuss your plan with your provider if necessary to determine what plan if any is in your best interest. Dr. Cisneros maintains a practice in Freeburg and Columbia, IL. Both are in the Greater St Louis, MO area. For more information on a wide variety of subjects, please visit www.advanced-smiles.com.