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  • Writer's pictureThe Tooth Doctors

Why Doesn't My Insurance Plan Cover the Treatment My Dentist Recommends?

Updated: Jul 10, 2018

by Christine - Why Doesn't My Insurance Plan Cover The Treatment My Dentist Recommends?

Simply put; To. Save. Money.

The following is a response from an insurance company to an estimate that was submitted by our office on behalf of a patient for treatment that was recommended:   “when two or more types of treatment covered under this benefit would produce professionally adequate results, your plan will consider benefits as if the least expensive type of treatment is used”

Dental Insurance, Dental Plan, Insurance
Did you know that Insurance only pays for "adequate" results

.... because, what we all want is simply  “adequate results ...” (insert sarcastic tone here)

In this scenario, the tooth in question needs a crown. But a basic filling is all that is covered by insurance. Does this mean Dr. Wong should just do a filling? Absolutely Not! This is not a decision that the insurance company should be making on behalf of the patient (who's tooth they have never seen clinically) It is Dr. Wong’s job to provide the best treatment based on his diagnosis and prognosis for the tooth. It is also Dr. Wong's responsibility to educate the patient over why the crown is the best treatment option and what the risks involved in not proceeding are. It is the patients job to make the best informed decision for themselves. And it is the insurance company’s job to save (make) money.

Unfortunately , it is common for dental insurance to cover the “least expensive alternative options” (regardless of whether it is the best option for the patient) Dental insurance isn’t really “insurance” by definition (a payment to cover a loss) but rather a benefit typically provided by an employer to help their employees pay for routine dental care. Most benefit plans are only designed to cover a portion of the total cost and many plans do not pay for anything beyond basic care (utilizing the most basic materials) The amount of coverage is determined by how much the employer pays for the plan.  If dental plans were more inclusive (in that they covered more) the premiums would be higher and if the premiums were higher, employers would be less likely to purchase the plans.

Many insurance companies indicate that they cover a certain percentage of eligible services (commonly 80-100% for basic treatment), but what we find is that sometimes that is 80-100% of what the insurance company allows as payment towards the procedure(s), not what the dentist may actually charge. Often times, this is at the rate of a previous year(s) fee guide (whereas the majority of dentists charge fees based on the current fee guide rates)

Sometimes insurance companies wont pay anything towards some procedures. This is usually because they limit the frequency that a procedure can be billed. This happens often with cleanings, fluoride, treatments, x-rays and continuing care exams. While the suggested frequency of these types of appointments can change from patient to patient (based on their clinical need), the recommendation is often that we see our patients for preventative services at least two times per year. Many insurance companies cover only one time per year. We do our best to help our patients stay within the parameters of their insurance plan where possible, but also maximize their benefits to allow more frequent cleanings. Because, what is the old saying? ... "an ounce of prevention". I think we would all agree that by seeing a dentist for more frequent preventative appointments, there is a good chance that small dental concerns can be addressed before they become larger, more costly, and/or more painful dental concerns.

Insurance companies may also restrict eligible fees to certain types of materials. For example, many insurance plans restrict the use of white tooth colored filling material to front teeth. For molars they will only reimburse up to the amount that they would allow for silver amalgam (mercury!!??) filling material. We commonly see patients restricted to the cost of a full metal crown because their insurance company does not cover a tooth colored porcelain crown. There is no regard over quality of materials used – it is based on the least expensive option that will provide “adequate” results.

Did you know that in the 1970s, the majority of insurance companies had an annual maximum of $1000? Today, more than 40 years later, many insurance companies have an average yearly maximum of $1000-$1500. Inflation may have catapulted the rate of the dollar over the decades, but the reimbursement rate for dental insurance hasn’t changed much.

As health care providers, our relationship is with our patients, not the insurance companies. The insurance is a contract between the patient, the employer and the insurance company. We are not party to that contract. As dental professionals, it is our responsibility to diagnose and make treatment recommendations to our patients based on their clinical need and what treatment is best for them. At our office, we are guided by the principle of “what would I do for my family?” We will always present all available options to our patients, but we will never make treatment recommendations based solely on insurance coverage. We will be fair and consistent with all of our patients, but unfortunately have no control over what insurance companies do or don't cover and at what rate. Our treatment fees are based on the Ontario Dental Association recommended fee guide, the materials we use and the education level of our team.  We will always work as an advocate for our patients to make sure that they receive the very best treatment and where possible, will help our patients understand their insurance plan and its limitations as best we can.


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