November 8, 2011

Dental Insurance: Is Not Really Insurance: Insurance Tricks of the Trade


What is dental insurance?  It certainly isn’t insurance.  It would be better described as an allowance.  An allowance that is really your money paid back to you by very stingy parents.  You would be much better off putting the money you spend on dental insurance into a savings account than giving it to an insurance company. They run a large-scale business, and they have to pay dividends to their shareholders from it.  The problem most people find is that it is very difficult to put money aside for rainy-day dental needs.  If the money isn’t put away “safely” with the dental “allowance” company, it would most likely be spent on the kids, the car, the house, the vacation, etc.  Instead, billion dollar corporations get fat off of managing the money for you.  Isn’t this a crazy world where an entire industry parasitically sucks the life out of your wallet so you can think you are staying healthy?

We at Cape Dental Care, like many other dental offices,  hold ourselves to a standard that is very high above most insurance companies. We do not compromise our scientifically-backed treatment protocols to dance to the song of the insurance companies bean counters. This blog will be dedicated to exposing some of the tricks of the dental insurance trade that are designed to stifle dental offices from filing claims for their patients.  After all, if the insurance companies can discourage the dental profession from filing claims for their patients, then the insurance companies have won BIG! Because if we in the dental field suddenly throw up our hands in disgust, and quit hiring front desk workers to sit on the phone for hours at a time to figure out these tricks of the dental insurance trade, then who would file claims for the patient?  I am convinced that this is exactly the strategy of the dental insurance companies at large.

Tricks of the Dental Insurance Trade:

  1. Only reimbursing for the “Usual and Customary Rates” (UCR):  These are the biggest joke!  Completely made up figures from the very distant past that the dental “allowance” companies use to deny patient claims.  This is a ploy they use to drive a wedge between the patient and the doctor’s office.  They are essentially saying to the patient, “Look, it is not our fault you have to pay more for this procedure, everyone else charges only this smaller amount”.  This implies, of course, that the patient has gone to a high priced dental practice.  The only problem with this is that NO ONE in the area could survive in the dental business with such low fees, and that the fees they are quoting are from the 1960’s. Insurance companies have been sued by dental organizations in the past to find out where in the world they came up with these figures, but the practice is still used with impunity.
  2. Not doing certain combination treatments:  The patient comes in for a routine cleaning.  In the middle of getting a cleaning the patient tells the hygienist that they also have a toothache.  The dentist is called in and gives them an emergency exam and finds an abscessed tooth.  The dentist has an opening after the cleaning, BUT NO! The insurance company will not pay for the emergency or the required treatment to relieve the toothache because it is done on the same day as a cleaning. Really?
  3. Sealants time periods: Some insurance companies will pay for a certain tooth’s sealant only during certain ages.  For example, permanent 1st molars can be sealed only from ages 6 to 8.  This means the patient cannot have all their teeth sealed at the same time.  This obviously ONLY benefits the insurance companies bottom line.  Bean counter!
  4. One of my personal favorite tricks of the trade is when we send several claims to a dental insurance company in one envelope to save on postage.  Did you know the dental insurance claim adjuster gets paid by the number of pieces of mail they handle?  You may have sent in 5 claims in one piece of mail, but some how only one gets processed and the other 4 are mysteriously lost.  Laziness!
  5. The patient comes in for an appointment for a broken front tooth.  The tooth is non-restorable.  The dentist quickly makes a transitional partial denture (flipper) so the patient can look normal when they smile.  This is a temporary denture designed to be in the mouth only up to a year.  After that a more definitive permanent restoration needs to be made which in some cases is a cast metal partial denture.  This is a very logical treatment plan to take care of this problem that the dental Insurance company says they will “insure”.  However, since this temporary denture was filed with the insurance company, they will not pay for another partial for 5 years because they consider it to be permanent.  This is why we make sure if the patient wants to file for the much cheaper temporary denture or do they want to wait and file for the definitive cast metal partial denture at a later date. The insurance company is of course banking that you will want to file for the less expensive temporary denture to help their bottom line.  Pirates!
  6. Guardian will not pay for a diagnostic PA x-ray during a limited exam for a toothache if a follow-up root canal is done within 14 days.  They consider this part of the root canal treatment.  What a joke!  Example:  A patient came in for a toothache and we gave him the usual options of either saving the tooth or not saving the tooth.  He didn’t want the tooth extracted so we opted for a palliative pulpectomy.  Days later he scheduled for a root canal for which we performed a week and a half later.  The insurance company wrote off the original diagnostic x-ray because they consider this part of the root canal treatment.  When called they said their policy was not to pay for a PA x-ray if it was done within 14 days of the root canal treatment. Ridiculous!  Even the patient thought that was the stupidest thing he had ever heard.
  7. A patient comes into our office with a sore tooth.  The tooth just had a CERAC crown made by another dentist.  It was  diagnosed as irreversible pulpitis, and needed Endo.  I did the Endo, and a week later filled the occlusal access with the “Vertise composite technique”.  Her Delta Dental Insurance is now refusing to pay for the Endo access fill through the CERAC because they are now including this filling with the Endo treatment.  We had to send the patient the bill telling her that her insurance is weaseling out of paying for her treatment with a NEW technique of decreasing her benefits. Cheats!
  8. We at our office do not usually take 2 or 4 bitewings on adults.  We feel that the front teeth deserve the same attention as the back teeth.  Instead we take 7 vertical bitewings.  If we were to send in the code for 7 vertical bitewings to an insurance company and they refused to pay, they are now refusing to let us down grade the code to 4 bitewings even though they are due for those radiographs.  Their reasoning is unclear and are telling us that once it is sent in for consideration, it cannot be reconsidered.  Boo!

Please add your “Dental Insurance Story” to this website in the comments section below!