I was at the gym this afternoon and I bumped into a patient/friend of many years in passing thru the locker room. “Hey Billy, what’s up?” , I said. With a sense of frustration, he replied, ” I looked into getting dental insurance. I know I need another crown on that troublesome back tooth of mine and they ( the dental insurance company ) said that they won’t cover the crown just yet. Apparently, there is a year waiting period before they would consider paying for a portion of that restoration and or any other major work needed. I don’t get it . I pay a $150 a month and they don’t cover anything for a year? What bullshit! It doesn’t add up. I thought I would be saving money”, he said.
There is a big mystery around dental insurance. Let me shed some light on it with a few of my thoughts.
In general, dental insurance can be a plus, especially if you don’t pay for it. When subsidized by an employer, it’s great. Dental insurance usually covers 100% of your cleaning, radiography and examination. Consider it a gift by your employer when you have great teeth and limited income.
When you are in the majority, not blessed with great teeth, dental insurance can also be a bonus. You will have access to a discounted fee schedule. As a provider of many insurance programs, I am contracted to offer you a lower fee from the U.C.R. (Usual Customary and Reasonable fee) U.C.R. In return, as a dental provider in a competitive market, I don’t have the financial expense to promote my business. Quite simply, there’s a process or strategy most people utilize in choosing a provider. Most commonly, you first ask friends for advice, you then look in your company’s list of dental providers, search the web for additional reviews, also consider location and then make your appointment. It’s a Win-Win for both you the patient and me the provider.
Let’s exam Billy’s Situation . Billy’s an independent, non employed, individual who acquired insurance on his own merit. He is paying $150/month for a dental benefit.
Here’s the first caveat: In General, The dental carrier will provide partial coverage for some minor dental work and total coverage for cleanings and routine exams throughout ownership of the plan on a yearly agreement. MAJOR WORK SUCH AS CROWNS, BRIDGES, ROOT CANALS WILL NOT COVERED WITHIN THE FIRST YEAR. The expensive, major stuff will not be covered until after the first twelve months of enrollment.
Second caveat: Look for this winner. The MISSING TOOTH CLAUSE. This little line item cleverly inserted into the agreement which allows the dental insurance company a loop hole. Insurance companies will have no obligation to pay towards a Bridge (dental bridge) procedure if the missing tooth within the span was extracted Prior to the agreement. Not applicable here to Billy, but noteworthy.
Consider the simple math for Billy:
$150/month X 12 months =$1800 into the first year. This is Billy’s Out of Pocket premium.
In Year One, The Insurance Company will pay 100% for: cleanings, exam and X-rays
Assume (2) Cleanings /year & (4) Bite Wing radiography & (2) exams = around $400 for the year
Assume , two small restorations = $400
Insurance company netting approximately in year ONE:
$1800-$400-$400=$1,000 for the insurance company in profit
In Year Two (For arguments sake, LETS MAKE A potential scenario BASED ON MY MANY YEARS OF EXPERIENCE)
Finally, a year passes. Billy patiently waits and he finally gets that Crown. “Bam”……that problematic tooth that which I told him to get crowned last year, now needs a root canal procedure. Reluctant Billy, waited a whole year for that benefit to “kick in”. In doing so that pesky decay had a wonderful opportunity to eat its way into Billy’s pulp. Talk about pain, in the wallet too.
Procrastination in order to utilize the allotted dental insurance benefit will have cost an additional expense of an unnecessary the root canal.
Potentially, NOW………Total treatment:
$1000 for the crown + $800 for the root canal + $250 extra stuff =$2050 cost
For the Crown– Insurance will pay $500 minus the deductible ( This is an annoying term. It is a little fee that the insurance company tacks on. It is a one time administration processing fee that gets applied every calendar year. This deductible is usually around $100. Therefore. The insurance company will contribute a net of $400 towards that crown.
For the Root Canal– The company will contribute 80% towards the root canal procedure. My fee for a root canal is $800. Eighty percent of that is $640.
Factor in 80% for ancillary items, the company’s contribution of $200 toward the $250 charge.
In Summary. If we do the math, the insurance company should contribute:
$400 for the crown +$640 for the root canal + $200 for the other miscellaneous stuff associated.
The Insurance Company should be contributing $1240 .
The reality is the following: The dental insurance company industry standard customarily have a set MAXIMUM ALLOWED BENEFIT FOR EACH YEAR. This amount is usually stands at $1,000.
Question: Does Billy intend to get his teeth cleaned this year? B.T.W. . That’s outside his allotted benefit. He used his allotted money up on the unneccessary root canal. Sorry Billy, more out-of-pocket.
Billy is out-of-pocket $1800 first year with minimal benefit
Billy is out-of-pocket $1800 second year with minimal benefit
In his second year, after the root canal and crown, he’s out-of-pocket an additional $1050
Assume (4) cleaning in this two-year span: $400 X 2 = $800
That crown and root canal and maintenance cost Billy $5,450.
Where is the savings? I believe Billy should just get that crown down tomorrow and save himself some money.
Dr. Emilio Always Accepts New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.
His goal is to keep his patients’ Teeth and Gums Healthy For Life.
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