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Dental

2003-03-01 13:26:00

I never know what my dental insurance

:  My dental insurance says it will pay for dental work at 100%, 80% and 50% depending on the procedure, yet that doesn't always happen.  What gives?  Is it because my dentist is not a participating provider?

ANSWER:  To say the least, it is frustrating for one to be led to believe 100% of a bill will be taken care of by a third party only to find out that such is not the case.  The answer is quite complex.  The information required to answer your questions is generally found in the fine print of the contracts and employee benefits booklet.  First it is necessary to clarify terms and concepts.  In your question, you used "dental insurance" to represent a company as opposed to a "third party administrator", which would be a more accurate term.  The term "dental insurance" used as a benefit is more accurately termed "prepayment of benefits".  True insurance is coverage for the unexpected or events that are unanticipated.  Other than trauma or cancer, oral disease is very predictable, and even in those situations, there are some steps that one can take to lessen the chances of injury or disease, like wearing a mouth-guard for sporting activities and not using tobacco products.The Plan is what an employer wishes to provide employees as a benefit of employment rather than having all compensation in the form of salary.  Salary compensation is subject to taxes withheld for Social Security and Medicaid, with an equal amount paid by the employer.  Therefore, pretax benefits are a win-win situation for both the employer and the employee.  For the Plan to succeed, it is necessary for it to be on sound financial ground.  Actuaries know within narrow margins of error just how many people in a group, based on data obtained over many years, will need what dental services. They then advise (based on the funds available for providing dental benefits) third party administrators the limitations and amounts that can be allowed for each of the services to be built into the plans.  This assures the plan will be financially viable.  At this point the employer chooses either a Direct Reimbursement Plan or selects an insurance company to serve as the Plan Administrator.  The major factor in the development of any Benefit Plan is how much funding the employer can spend annually over a three to five year Plan Contract.  After the Plan Administrator subtracts its fees, the total must then be allocated between the services expected to be claimed as benefits.  Obviously, the Plan cannot pay 100% of all claims unless the employer has unlimited funds.  Because of limited funding it is necessary to limit the expenditures to considerably less than the cost of providing the benefits.  The major restriction or limit placed within the Plan is its yearly maximum.  There are few policies that exceed $1000.00 in annual benefits, which by the way was the annual maximum well over 30 years ago when dental plans emerged as an employee benefit.  Other limits that are listed in the contract language include deductibles, co-payments, non-covered services and the phrase "the least expensive procedure that provides professionally acceptable results".  Deductibles and co-payments, if not collected, produce over-utilization which in turn causes a rapid depletion of available funds set aside to pay benefits, thereby potentially allowing the plan to become insolvent.  That is the reason it is generally considered a fraudulent practice for dentists to "forgive" the deductible and/or co-payments that are stipulated in the contract as the patient's financial obligation.  The phrase "the least expensive procedure that provides professionally acceptable results" is used to save money by paying for an alternative treatment rather than the procedure you and your dentist decided to have accomplished.  The alternative treatment is not determined by you and your dentist, but by a dental consultant.  This person, possibly not even licensed to practice dentistry in your state, is hired and paid by the Plan Administrator.  This may not seem fair but it is in the contract language.  Contract language is extremely important in controlling costs and promoting the plan to potential purchasers.  This is where your question's focus lies.  It sounds more enticing to consider a Plan paying 50% of crowns rather than say $260.00 for a crown.  An employer may have the knowledge of fees charged for a crown restoration, but not really understand the fine print that explains the 'percentile' allocation as it relates to 'usual, customary and reasonable' terminology in the contract language.  We now have new words to define: "Usual, Customary and Reasonable" (UCR) and "Percentile".  Using the 50th Percentile fee means that half of the dentists providing that service will have a fee at or below that level and half will have a fee for more than that amount.  For dentists with a fee at or below the percentile stipulated in the contract the patient will be reimbursed by the plan administrator, a full 50% of the fee.  For dentists with a fee above the stipulated contract percentile, the patient will be reimbursed 50% of the maximum allowed by the contract language.  The portion of the fee above that level will be owed by the patient as a co-payment, unless the Plan discriminates on the basis of being a PPO, DMO or a Point of Service Contract.  That gets to the point of your second part of your two part questions. (I warned you it was complex).  Not all plans require the patient to have the services provided by a preferred provider to be reimbursed or be reimbursed at the highest level.  Those that require preferred providers also require a participating dentist to sign a contract.  From the dentist's side, signing a contract and thus becoming a preferred provider presents a legal document necessitating him/her to abide by the contract in all aspects of the obligations written in the contract and generally include any changes the plan administrator might institute in the future.  The dentist has a way out of the contract if he/she doesn't like any new language, but risks loosing patients that expect the doctor to write off all fees above the contract limits.  That poses a financial dilemma if not an ethical dilemma, for the dentist, which is not easily addressed.  If your policy allows you to select the dentist of your choice and doesn't require a contract with participating dentists, the policy will still impose limits on their liability in the policy and require you to pay the difference rather than requiring the dentist to write off the balance.I hope that your questions were answered, or at least some light shed on the subject.  Above all, select your dentist based on what you feel is important and not on whom a Plan Administrator prefers.  They may prefer someone for reasons that don't mesh with your reasons or values.  Select a dentist you know and trust.  Wichita is blessed with having a high percentage of excellent dentists.Bottom line is that Dental "Insurance" Companies are in business for a profit.  Even those that are officially non-profit in structure desire more income as it can be used to increase benefits for the officers and employees.  Limits on payouts increase the bottom line profits.  The good news is that pre-tax benefits allow people to take advantage of dental benefits, increase their dental knowledge and obtain access to improved dental health.  We can all be grateful that government in spite of all its shortcomings, on the issue of pre-tax benefits, "promotes the general welfare" of its citizens.