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Dear Patient: Your dental insurance company doesn’t care about you

Maybe not. Is dental insurance the deal you think it is? Let breaks down the benefits and suggests patients take a hard look at whether their insurance plan is helping them in the long run.

First, let me start by saying there are many amazing people who work for dental insurance companies. I have lots of very caring, kind, compassionate friends who do indeed care about the clients and want what’s best for them. But what I’m talking about here is the business of dental insurance.

The dental insurance business is just that, a business, where the end game is to make money—sometimes with little regard for patient outcomes.

Dental insurance came about in the 1950s as a union benefit. In 1970, preferred provider organizations (PPO) were established and dentists were encouraged to sign on and offer reduced fees for members in exchange for sending patients their way. This plan still allowed patients the freedom to choose an out-of-network dentist and pay the difference in fees. Then in the 1980s health maintenance organization (HMO) plans emerged that reduced fees even further but promised monthly per-patient payments to a small list of member dentists.

While the concept of dental insurance is a great benefit, encouraging some measure of compliance and financially helping patients prioritize dental care, in my experience, there are flaws in the system that place barriers to optimal dental care. Many people think dental insurance pays for the best available treatment. But in my experience, that’s not always the case.

Yearly benefits have barely changed—in 60 years

While insurance typically covers 100% of standard preventive care, it often only covers 80% of basic restorative (such as fillings) and 50% of major restorative (such as crowns). And all those percentages are based on fee schedules created by the dental insurance company, having little to do with what it actually costs to provide those services.

The Centers for Disease Control and Prevention (CDC) reports 47.2% of adults aged 30 years and older have some form of periodontal disease.

Periodontal disease increases with age; 70.1% of adults 65 years and older have periodontal disease. “Standard preventive care” is no longer enough for someone with active disease.

This is where your yearly benefit comes in. Way back in the 1950s and 1960s when dental insurance came to be the yearly benefit or maximum allowance (meaning how much money the insurance company would pay each year), it was $1000. And 60-plus years later it hasn’t moved much; maybe it’s at $1500 if you’re lucky. A crown in my clinical office costs more than that! If insurance had kept up with inflation and advances in dentistry, your maximum allowance should be around $10,000.

Arbitrary coverage

Next is what they do cover and the barriers to getting that coverage. As a dental professional with years of schooling, yearly continuing education, and clinical experience, I feel confident that my dentist and clinical team can offer the best recommendations based specifically on your needs and desires. We have spent time with you getting to know your goals, evaluating your specific condition and risk factors. But to have an insurance company tell me they know better from a 2D x-ray and words in a paper chart is frustrating. And their setting what seem like baseless limitations to treatment makes us want to pull our hair out.

There are strange, seemingly arbitrary rules to play the insurance game. As a hygienist, I can’t do a whole mouth nonsurgical periodontal therapy in one appointment regardless of your schedule. It must be done in at least two appointments. Or if you have a high rate of cavities, your fluoride might still not be covered. Or some insurance companies will pay for x-rays every six months and others every two years. Professional judgment is not allowed here, only what’s in the coverage.

Do the math

If you add up what you’re spending on dental insurance, you might find it’s not worth it. Not only might you lose the ability to choose a dentist that you’re most comfortable with, but you might also end up paying more out of pocket for the ideal treatment rather than accepting the less-than-ideal treatment the dental insurance will actually cover. For the most part, good dentistry is predictable and/or preventable.

In all honesty, if you want dental care that will last and be free of hiccups, select a dentist that has a reputation for long-lasting dental treatment. A comprehensive evaluation can let you know issues that might arise so you can plan for them. An excellent dentist who can recognize issues before they become problems can save you money—and your teeth!—by being proactive.

Some experts say dental insurance reached its peak in 2017, and participation is now trending downhill. COVID-19 has given many dentists an opportunity to evaluate their overhead and decide that being “in-network” wasn’t worth it. With so many dentists refusing to accept the arbitrary insurance fee schedule that sometimes doesn’t even cover the hourly wage of the team—along with the popularity of health savings accounts and membership plans—smart consumers can now access optimal oral health care within their budget, and in keeping with their health and wellness goals.

So instead of asking what your insurance will cover, ask: “How will this impact my overall health and wellness?”

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