|
Too often, we only hear dentists and other
health professionals complain about the paperwork and intrusions
into the doctor/patient relationship that come with dental
insurance. It is only fair to give the insurance industry
the credit it is due in making modern preventive dentistry
available and widely used by the general public. Regular dental
checkups and preventive care were once common only in the
upper middle and wealthy income groups. This was never a good
idea. The person who cannot afford expensive rehabilitative
dentistry needs prevention more than someone who can afford
complex dental care, but the simple truth is that before dental
insurance became widespread, the average person did not seek
regular dental checkups and saw a dentist only when pain alerted
the patient to his need for dental care. Millions of people
now get regular preventive care who in the past might not
have done so and the nation's dental health is much better
for that change. Now, with increasing pressure on employers
to reduce healthcare costs, that great benefit to the public
is in danger.
There are several types of dental insurance
and assistance plans. More briefly, the plans fall into these
categories:
...are the traditional form of dental insurance. You are
free to choose your own dentist without penalty. The plan
pays all or part of the dentist's fee to the extent that it
does not exceed the Usual, Customary and Reasonable fee, or
UCR, for that service. Insurance companies calculate the UCR
in differing ways, but it is usually between the 50th and
80th percentile fee for the area. A typical indemnity plan
will pay 100% on preventive services, 80% on common restorative
services, and 50% on major treatments such as crowns, prosthetics,
and orthodontics. The payments are usually limited by a yearly
maximum payment and there is sometimes a deductible which
the patient must pay before coverage begins. Most well designed
plans do not apply the deductible to preventive services in
order to encourage you to make use of those cost saving services.
Most dentists now accept assignment of insurance benefits
which allows the insurance company to pay the dentist directly
for its portion. The patient is responsible for the portion
of fee not paid by the insurance. It is amazing that the UCR
fee varies between insurance companies and between different
plans in the same company. This is because benefits are determined
by the premiums paid for a particular plan.
...are similar to indemnity plans in most ways, but patients
are offered financial incentives to select their dentist from
a list of dentists who have entered into an agreement with
the insurance company to accept a pre-set fee. This pre-set
fee may be the average for the area or some discounted amount.
The plan may pay a higher percentage or eliminate the deductible
when a participating dentist is chosen to induce patients
to select a participating dentist. Further, the dentist agrees
not to charge the patient for any amount that his normal fee
exceeds the pre-set fee. For example, under an indemnity plan,
if a dentist charges $105 for a service covered at 80% and
the UCR for that service is $100, the insurance will pay $80
and the patient is responsible for the other $25. Under a
PPO plan with similar coverage and a pre-set fee of $100,
The insurance would pay $80, the dentist would write off the
$5 by which his fee exceeds the agreed amount, and the patient
would be responsible for the remaining $20.
...pay a fixed amount for a given service, regardless of
the what the dentist charges. The patient is responsible for
the remainder. Such plans can be quite good if they keep up
with inflation, but few do. Mailhandlers, common among Federal
employees in this area has not adjusted its table of allowances
for almost ten years.
...are not dental insurance at all. Under these plans you
must choose a participating dentist to receive benefits. These
plans are of 2 types:
Capitation: The dentist receives a small
monthly payment for each patient he is assigned. He is not
paid for any preventive or restorative treatment he provides
by the insurance company except for that capitation (by
the head) payment which he receives whether he treats you
or not. Since treating patients costs the dentist money,
he fares best if he does not treat his patients at all.
This is a clear conflict of interest. I consider all of
these plans to be fundamentally dishonest and I do not participate
in any of them.
Fixed fee for service: The plan provides
a fee schedule for the patient that they have arranged.
This fee schedule sets the fees so that it is in the best
interest of the dentist to cut costs in order to make a
profit. It pays to use low quality low cost laboratories
because the use of a high quality lab may eliminate any
profit a dentist might have.
...are commonly "included" in membership in some
organization. The "insurance" pays nothing to the
provider at all. Typically, in return for having patients
from the organization referred to his practice, the dentist
provides "free" examinations and gives some percentage
discount to the members. There is no checking of the fees
by the plan, so dentists participating in these plans can
simply boost their fee enough to make the discount meaningless,
much as is often done in going out of business sales at bankrupt
stores. A good rule, both in dentistry and elsewhere in life,
is that anything you are given for "free" is worth
every penny you paid.
...are the newest entry into dental care cost assistance
and hold great promise. The American Dental Association is
promoting Direct Reimbursement Plans and provides and assistance
to employers in establishing these plans. The insurance companies
are bitterly opposed to them, largely because they eliminate
the insurer altogether. In Texas the Texas Dental Association
has established Paid Dental. The patient pays for his treatment
(many dentists will accept a post-dated check) and brings
the paid receipt to his employer to be reimbursed in whole
or in part. The percentages of reimbursement are based on
the benefits used. A typical plan might pay 100% of the first
$200 of dental expenses, 80% of the next $500 and 50% thereafter
until an annual maximum of $1000 is reached. Because the patient's
share of the expense increases as more benefits are used,
the patient is discouraged from overuse of the benefits and
encouraged to use his shopping skills to get the most for
his and his employer's money. Any additional cost incurred
by allowing the patient to control his own treatment is more
than made up by eliminating the insurance company's processing
costs and profits. These plans may hold the key to providing
effective dental cost assistance while providing employers
with savings comparable to the managed care scams and maintaining
real benefits to the employees.
source: http://www.qualitydentistry.com/insurance2.html
For over 30 years, dentist Dr. Michael Potts D.D.S. has served Ventura County, California for dental implants, cosmetic dentistry, and general dentistry. Dr. Potts is a dentist who is excited about new cosmetic concepts in dentistry. He also places and restores dental implants in the same office. We have a great staff, the right equipment, and an on-site laboratory to serve you professionally and quickly!
|
