About Insurance Plans
While dental insurance started out as a good idea whose time had come--and it was. Some things have happened recently to change that. A significant increase in so-called "managed care" plans has occured. These plans are supposed to help stop run-away dental care costs.
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Lest you believe that all rising healthcare costs are the fault of the dentist, consider that dentists' incomes have not kept up with the cost of living in 22 of the last 23 years. Dentists have to pay salaries, insurance, rent, taxes, phone bills, power bills, etc., just like every other healthcare provider.
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Meanwhile, insurance companies are recording record profits and bonuses to their CEO's range as high as 15 million dollars and we won't even talk about salaries, stock options, fringe benefits, etc.
OK, let's see now, where could all that money be going? Enough about that. What about those "managed care" insurance plans?
"Managed Care" plans limit the patient's freedom of choice and many of us believe these plans decrease the quality of care that the patient receives. If your employer, trying to cut benefit costs, offers you a choice, here are some things to know and understand so that you can make the most informed decision as you compare the various plans you may be looking at.
- Always remember that it is you who is ultimately responsible for paying the healthcare provider. The insurance company is ultimately responsible for paying you.
- No insurance plan covers all dental expenses. There are varied ways of handling it, but essentially, there is always a "deductible" amount in every plan. You will be responsible for payment to the healthcare provider of the deductible amount. There will also be procedures and, perhaps, office co-payments associated with your plan and, again, You will be responsible for payment to the healthcare provider of these amounts. You should know up front that many of the procedures that will not be covered are routine procedures, so you will almost certainly encounter these limitations in your insurance plan.
- Your insurance plan is based upon a contract between your employer, or you if you deal directly with them, and the insurance company. Specific questions about all facets of the insurance plan can only be answered by the insurance company and/or your employer.
- All insurance companies make a profit and stay in business by charging more in premiums than they pay out in claims. Hence, if they can pay out less in benefits, they can make a larger profit. In addition, since money held earns interest, they can increase their profits by delaying payments as long as possible. This is one reason that healthcare providers are often required to send in "pre-treatment estimates" on more expensive procedures--it creates a greater delay before the payment must be paid. Of course, it also creates a greater delay before the patient receives proper attention and treatment, too--and it can sometimes be a delay that is very painful or allows the patient's health to worsen considerably.
- Insurance companies often use the term "usual and customary" to describe what they will pay for a given procedure. In order to back this up, they formulate fee schedules which they tell your employer they will go by. The problem is that the fee schedules are often set too low--a back-door way of lower the amount of benefits that are paid. Urge your employer to get and research the fee schedule before accepting a contract with an insurance company. Remember, it is a case of the fox guarding the hen house when the insurance company sets the fee schedule in a vacuum--"usual and customary" can cost you a lot of money because it is you who must pay the healthcare provider the difference.
- Then, there's the "maximum annual benefit." Many employers have had the same dental plan with the same company for years. Each year, they agree to a premium increase because, as we all know and the insurance company will be extremely quick to point out, "healthcare costs have risen." What they won't point out so quickly is that the "maximum annual benefit" and "fee schedule" (see above) may not have changed much at all during those years...that's the way they like it. Talk to your employer about this and ask pointedly what the maximum annual bennefit is. Then check with your dentist (and other healthcare providers you use)--you may be surprised.
- "Managed Health Care" plans force the healthcare provider to accept significant decreases in what they are paid for the services they provide. This has ramifications for your treatment that you may not be aware of. Talk to your healthcare providers about this before you opt for a "managed" plan.
- "Managed Health Care" plans force you to use a dentist who is a "member" of the plan. You are restricted in your choice of medical professionals, regardless of your condition or who you want to have treat you or why.
In general, it is our opinion that under a "managed care plan:"
- The dentist is encouraged to do the least amount of work that is possible regardless of the patient's well being and health.
- The dentist is tempted, if not encouraged, to use lower-grade supplies and laboratories to keep benefit payments "in line."
- Many offices will give a lower priority to the "managed care" patient than to a regular full-pay patient. This can range from preferential appointment times and courtesies all the way through the quality of care the patient receives.
Since Dr. Winchester has no intention of compromising on the quality of care he provides, we have chosen not to join a so-called "managed care plan." In this, Dr. Winchester is in the company of many American Dental Association members who all refuse to offer a lower grade of service and care to their patients.
| A Comparison of Dental Plan Types To Help You Make An Informed Decision |
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Traditional Indemnity Dental Insurance> |
Professional Provider Organization (PPO) |
Health Maintenance Organization (HMO) |
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The original plan and, we believe, the best. |
Provides services through contracted dentists who agree to accept lower fees. |
Minimum dentistry provided through contracted dentists who agree to small monthly capitation payments for each employee/patient regardless if services are performed or not. |
| Patient's Freedom of Choice |
Patients choose their own dentist or other
provider(s). |
Patients have more freedom of choice than with and HMO, but pay more for care from any non-"preferred" provider.
| Patients are restricted to a list of designated (i.e., contracted) providers--the most restrictive option.
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| Benefits to the Patient |
Coverage levels defined by contract. Generally, provides more comprehensive coverage than PPO or HMO plans.
| If services are delivered by a "preferred" provider, enrolled members receive those services at a reduced cost.
| If services are delivered by a "preferred" provider, enrolled members usually receive minimum comprehensive services.
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| Usage by the patient |
Can be controlled by the carrier--check the contract. |
Less controlled than an HMO
| Providers receive financial incentive to limit usage and keep benefits low.
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| Payments to the Provider |
Dentists are paid (indemnified) for services by the insuance company and the patient. |
Dentists are paid on the basis of a discounted fee schedule. |
Dentists are paid a small amount per member per month regardless of whether services are rendered to the member. |
| Cost to Patient |
More than a PPO or an HMO |
Less than a traditional indemnity play |
Least expensive |
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