Changing Your Perspective on Dental Insurance


(How to afford Dental Work or Financing)


Patients often view their employers’ dental insurance information with as much zeal as tax forms.    The dental terminology and treatment guidelines quickly become overwhelming, with good reason.  They prefer to skim the details and go for the bottom line.  Perhaps this explanation of dental insurance will spare you some aggravation.  First and foremost, remember that dental insurance does not equal dental “assurance” of payment.  Dental insurance was actually created in 1964 to offset the expense for routine dental work, not major reconstruction, with an annual maximum coverage of $1000 per person.  In most cases, that coverage has remained at $1000 per person more than forty years later, yet the effects of inflation reflect it as comparable to $6363.50 in today’s (2006) dollars.

Dental insurance cannot be compared to medical insurance.  Employers usually focus most of their attention on medical coverage because it often covers catastrophic, unpredictable situations that could prevent an employee from returning to work in a timely fashion.  Of course, medical insurance also covers more minor issues solved by diagnostic tests, antibiotics, and bed rest. Your body has a natural tendency to heal itself, once the cause of a problem is found.  But medical care does require an expensive infrastructure of facilities, on-call staff and equipment that, when utilized, could financially ruin people.  In contrast, dental care is manageable, usually not life-threatening, and maybe accumulates to even $50,000 over a lifetime. In medical problem this could be the bill for just one major sickness. Most dental problems cannot be healed by the body so must be fixed in an out-patient facility without admittance to the hospital. Since people can still work with a broken tooth or bleeding gums, employers don’t usually focus on this coverage.

Insurance carriers approach employers annually to establish or renew a contract, usually offering tiered coverage similar to auto insurance.  For instance, an employer can opt for Plan A, B, or C and each require a different payroll deduction.  Each plan also has a different configuration for paying benefits and the details are reflected in a lengthy Benefits Booklet. Once negotiated, the


Contract for these benefits is between the carrier, employer and the employee.  A dental office cannot possibly have a complete understanding of every negotiated contract for the plethora of plans.  It will submit a claim on your behalf but has no control over what or when insurance will pay.  Therefore, all questions about reimbursement should be addressed to an employer’s insurance representative.

A Basic Summary of Coverage

(Sidebar with these definitions:

*Carrier = an insurance company that agrees to pay benefits

*Group = the employment organization that has negotiated the insurance as part of a benefits                      package.

*Subscriber = the person representing the family unit as it relates to the plan; also know as the


*Provider = the dentist providing treatment

*Dependent = child or spouse of the subscriber)

Just like dentistry, the world of dental insurance is full of terminology that creates confusion.  If the foundation of insurance is boiled down, it covers some percentage of basic needs but rarely neglect. The highlights include:

1. Basic prevention such as exams, annual screening x-rays, and cleanings (prophylaxis) are usually reimbursed at a high percentage.

2. Minor restorations (fillings) made from silver alloy might be covered up to 80%.

3. Simple, single crowns might be covered up to 50% if the insurance company feels that there is no other way to fix the tooth.

4.  Multiple crowns and cosmetic procedures are rarely reimbursed because the insurance company has not realized the need to improve your quality of life.




Methods That Carriers Use to Limit Their Liability


All insurance companies have established a schedule of usual, customary and reasonable (UCR) fees that are designed to control the fees reimbursed per procedure in any given region, when practicing basic general dentistry.  Dentists are not forced, by law, to follow these fees which are often outdated because the insurance industry only updates them periodically.  Some plans implement a policy of “least expensive alternative treatment (LEAT)” that will reimburse for restorations at their stated percentage, but only when treatment is provided with the least expensive materials available.  For example, if silver alloy fillings are $80 and tooth-colored fillings are $120, the dental plan may reimburse 80% of the $80, even if a tooth-colored filling is placed.

Carriers also set limits on the frequency of preventive care and the length of acceptable service for major treatment.  Should patients require frequent recall appointments or receive sub-standard treatment that later fails, they may have to pay out-of-pocket.  Similarly, if a tooth has been missing before the insurance went into effect, carriers will replace missing teeth but strict guidelines exist for reimbursement on all or part of the procedure.  Some carriers have established exclusions for certain types of major treatment as well.

Dental plans that embrace the HMO and PPO philosophy have taken a different path.  For a relatively-inexpensive co-payment, dentists will address gross problems in an atmosphere of volume dentistry.  These plans have not helped patients achieve good dental health.

Occasionally, carriers establish a fixed-fee lifetime maximum for certain procedures.  The most common is orthodontic care.  If this benefit is offered, it states that a patient can receive up to a fixed dollar amount toward their care, usually $1000-1500, and the subscriber must pay the remainder.  The orthodontist provides documentation of care and the carrier sends partial payment checks throughout the course of treatment.



The Provider’s Role


When dental offices complete treatment, they submit a standardized claim form to the insurance company as a courtesy.  The insurance company usually reimburses the dentist, with the details of the reimbursement provided in an Explanation of Benefits (EOB) for the provider and subscriber.  Any remaining balance is the patient’s responsibility, as are delays in processing the

claim.  Most often, delays are blamed on incomplete data, missing signatures, or missing x-rays that occur from mismatched filing procedures within the insurance company.  When calling to figure out the reason, be sure to take down the name of the customer service representative who provides the information. Give this name, along with details to solve the problem; to a dental team member sp they are aware of the issue.

What Can Be Done?

Dental insurance should be viewed as a monetary supplement, not as the decision-maker for treatment and care.  It is unlikely that the policies behind dental insurance will change in the near future, and probably not within our lifetime!  An ethical dentist diagnoses your dental needs without concern for the mandates of the insurance company.  His focus is on the long-term health and function of your mouth.  That should be your focus and responsibility as well.  So how do you overcome the shortcomings of insurance?

There are now very creative financing programs available for dental care, with payments made on a monthly basis, much like you have for your car or home.  If people want or need these items, it is more realistic to spread the payments over time.  The same analogy exists for extensive dental treatment.  With this in mind, we offer the following alternatives:

1. We work with insurance to maximize the benefits to which you’re entitled.

2. Our office has become member with SEVERAL financial companies, who specializes in dental care FINANCING. In most cases with good credit, they can provide financing with ZERO INTEREST and approval occurs on-the-spot, after the completion of a short application. Complete process may take less than 10 minutes. We have become their members to make it easy and simple for you.  You don’t have to go anywhere and whole process can be completed with ease. Your financial information is kept confidential between you and the finance company.

3. We will finance your dental care up to 5 years, depending upon your credit rating.  Our office submits its paperwork and receives no information about your affairs.

4. We also work with a service that can pre-qualify payment for your care, before you come to the office, based on data that you provide directly to them.

5. We accept all major credit cards.

6. If you are uninterested in financing, we work with a company who accepts, holds, and guarantees post-dated personal checks that are cashed at pre-determined intervals throughout the course of your treatment.

7. We offer a discount for complete payment up front.

As you can see, when you come to our office, we will find a comfortable way to help you afford the dental care you need!   Cost of financing is lot cheaper than the cost of ignoring your over all health. Longer you wait more damage occurs to your health and mostly it turns into even more expansive options. People who need somewhat involved restorative dentistry (Multiple crowns, Implants, Multiple extractions and cosmetic work), can not rely on insurance to pay for it but with the financing options we offer you have no reason not to enjoy wonderful, healthy and beautiful smile.


Dr. Anil K Agarwal – Chicago and Orland Park’s Leading Prosthodontist & Implant Dentist

© Dr. Anil K Agarwal; Winterset Dental Care


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