What exactly is dental insurance and what makes it different from medical/health insurance?

To start off, let’s explain the difference between dental insurance and medical insurance.  One of the biggest differences is that medical insurance (or insurance in general) is there for catastrophic and unavoidable events, such as a car accident, hospitalizations, hurricane damage to your car, a house or an apartment fire, etc.… in which insurance companies pay out a lump sum for all of the damages done.  Usually this type of insurance has a large maximum payout ranging from tens to hundreds of thousands of dollars.

Dental Insurance does not quite work this way.  Dental insurance is for smaller unfortunate dental events and routine preventive procedures.  These include things such as hygiene cleanings, scaling and root planings, dental fillings, and maybe one to two large procedures a year, such as root canals and crowns. This type of insurance has a maximum yearly pay out maximum of usually between $1500 and $3000 which is predetermined by your particular dental plan.   Why do dental insurance companies do that? The dental insurers believe that dental procedures (other than preventive and routine procedures) are an avoidable occurrence.  The insurance companies believe if you cracked your tooth on a popcorn kernel, for example, that you should’ve been more careful and that was avoidable. As such, the insurance companies limit the amount of maximum payout to you, the patient. A dental insurance company usually covers only 50% of an avoidable dental event like a root canal. That is the insurance companies rule, NOT the dentist, in or out of network.

Examples of How Dental Insurance Works

For example, after you break your tooth on that popcorn kernel, your dentist decides you need a crown, but the insurance company denies the procedure. They decide that an extra large mercury silver filling would be adequate enough to fix your tooth. Why would the insurance company do that? They do that to save themselves the expense of a crown. So why isn’t Dr. Jeffrey Etess and Integrative Dental Specialists of Long Island in your dental insurance network? To explain that, you’ll need to see the other side of the story.  The side the dental insurance companies try to hide from you, the patient.

We Want The Truth And We CAN Handle It!

Each insurance company tells the dentist how much they will pay for each procedure.  So why is this an issue? Insurance companies are about making money for themselves, they do not care about your dental wellness and saving your teeth as much as their financial bottom line.  So they encourage dental practitioners to accept these lower fees, to use cheaper materials, and to use cheaper dental labs that are sometimes out of the country, which could potentially use tainted non-FDA approved materials. The insurance dentist must see patients much faster to see a greater number of patients to make up the financial difference in what is referred to as volume dentistry.  Cheaper labs, cheaper materials, quicker dentistry means lower quality dental care for you, the patient.

In-Network Dental Care

When a dentist applies to be on a dental insurance network, or panel, that dentist has decided to take a reduced negotiated fee for dental services provided from the insurance company. In exchange for a cheaper reimbursement, the dentist is published in your dental provider directory and the insurance’s online directory. Thus, the dentist’s motivation to take a lower fee is to attract more new patients to their practice. A dentist being in network with your dental insurance means that your insurance company will pay the dentist for your dental procedure minus your deductible (up to half) and your co-pay, of course, and only up to the maximum benefit allotted by your particular plan. Sometimes, your insurance company will completely deny a procedure for no good reason. Some insurance companies deny your claim or preauthorization without even reviewing it. How can this be true? Just click this link to read the truth: (https://www.law.com/nationallawjournal/2018/02/14/021418aetna/?slreturn=20180205002431)

Out-of-Network Dental Care

So what does out of network mean? Out of network means, we as practitioners, refuse to give in to the demands of the insurance companies to give you the patient, suboptimal care.  Out of network providers have the confidence that patients will come to their practices because they provide the best possible quality dentistry, not because they are on your dental plan. In exchange for top quality dental care, this means the insurance company will reimburse you directly a percentage of the procedure (the fee that the insurance company thinks what the fee should be, based on what it pays its in-network dentists, up to your maximum yearly benefits), leaving you with the excess balance.

Think of it like this, your insurance company says they’ll pay half the cost of your dinner tonight, so you go to The Outback and have yourself a decent steak dinner for $28.  The very next day your insurance company gives you back only $6 towards your $28 meal. You say: “Wait a second, you said you’d pay for half of my dinner!!!! To this, the insurance company says: “Well, we prefer for you to eat at McDonald’s, and you can eat there for only $12.  Outback is not in our network…their prices are too high, so we will give you half of $12, that’s our final answer.” This is the reality of dental insurance, all dental insurance.