Why Doesn't My Insurance Pay For That? | Blog

Patients who have dental insurance always ask the same question. Why doesn’t my insurance pay for this or that? What patients need to understand is that having dental insurance is not like having medical insurance that pretty much pays for everything and you just have a copayment. Dental insurance in fact is more like an assistance towards the cost of dentistry.

How dental plans work: Dental insurance is almost always a contract between an employer and an insurance company. Your employer and the insurance company agree on the amount of your plan and what procedures are covered. If you are not satisfied by what is covered by your plan, you should let your employer know.

Annual Maximums: Your yearly maximum is the total amount of money your insurance plan will pay during the year. Once again your employer decides that level with the contract of the insurance policy. The annual maximum is not always updated to catch up to the cost of dental care. 

Plan Frequency Limitations: Your dental plan may limit the amount of times it will be pay for certain treatment. For example; if you are a patient with periodontal disease and require additional cleanings to maintain a healthy mouth, your Insurance may only pay for two cleanings when indeed you need four cleanings. Making treatment decisions solely based on what your insurance pays for is not the answer, make your decisions based on what’s best for your particular situation.

Controlling Costs: There are many different ways your insurance will try to control the costs to which they are spending when it comes to dental coverage. Here are some of the things they do. Bundling; for example your dentist completes a core and crown on a tooth that has a large filling in it, your insurance states that a core is not covered and it’s worked into the crown fee. Not all insurances do this but some do. Downcoding; for example your dentist completes a bridge on the upper right side but since you are missing a tooth on the upper left also they downgrade the bridge to a partial denture. Least Expensive Alternate Treatment; What this means is that if there is more than one way to treat a condition, the plan will pay for the least expensive way to treat the condition. 

However, allowing your insurance to dictate what type of treatment you need is not always the best. Your dentist has been trained to base your treatment plan on the condition and not what your plan allows for you. You should always talk with your dentist to help you make the ultimate treatment decision based on what is best for your situation.

As always we would like to thank you for being part of our practice family!