All You Ever Wanted To Know About Dental Insurance

In this often frenetic day and age, the myriad confusion of dental plans is difficult for most people to understand. Please let me try to make some sense of it for you. Basically, dental plans fall into three major categories; traditional or fee-for-service plans, PPO or preferred provider plans, and HMO or health maintenance organization (also known as capitation) plans. Each of these has very different characteristics.

The fee-for-service plan is the oldest, and in most respects, the best. It is a copayment plan, meaning that the plan usually pays a certain portion of the dentist's fees and the patient is responsible for the rest. How well the plan pays depends upon various factors, mainly, how high a premium the plan purchaser (employer) is willing to contribute. The benefit payment schedule is usually linked to either the dentist's usual and customary fee for a particular service, or to a fixed table or "schedule of allowance". These plans' main advantage lies in the fact that they allow the patient to be treated by the dentist of his/her choice.

The PPO plan is a plan in which the plan contracts with certain dentists to provide care at a discounted fee for plan participants; in essence, dentistry at a discount. Depending upon the plan, usually the choice of dentists will be severely limited in number in a particular area. Also, the fees usually are heavily discounted. Not all dental services however are normally covered, and for many services there is no coverage at all, leaving payment entirely up to the patient. These plans cost the employer far less in premiums than fee-for-service plans and are attractive to some employers because of the cheap bottom line.

The HMO or capitation plan operates by paying the participating dentist a fixed amount per month or per year that is supposed to cover all the patient's needs. Frequently, as in the PPO plan, there are many services not covered under the plan that are the patient's ultimate responsibility to pay for. These plans are very cheap for the employer to purchase and are often nearly worthless to the patient as well. It is very curious that the HMO corporations and their CEOs are among the most profitable and highly paid of all businesses and individuals anywhere.

Actually a fourth option exists. This is called a direct-reimbursement plan or DR plan. In this plan, the patient/employee visits the dentist of his/her choice and then submits the bill directly to the employer, who pays all or part of it up to a certain yearly maximum. This type of plan represents the best of both worlds, in that the patients have their choice of dentists, and, the profit to the middleman (insurance company) is eliminated. This is the most cost effective plan as far as getting the most care for the employer's dollar. The California Dental Association and the American Dental Association have taken the lead in offering these plans to employers to use.

Let us now examine the economic motives of the various plans. First, understand that a dentist, like any other businessman, is in business to earn a living. Economic motivation is the sole reason for participating or not participating in a particular plan. In the HMO or capitation plan, the economic motivation is to see patients as seldom as possible and provide the absolute minimum in care, since the capitation payment is the same whether or not any dental work is done. You can see that this is a distinct disincentive to providing quality care. The performing of non-covered procedures is where the profit lies, so there is an incentive to do these, often unnecessarily. Most reputable, ethical dentists do not participate in HMOs because the economics would force them to compromise their quality and patient access too much. PPO plans, because of the economics involved, force the dentist to produce more work and work faster. This, too, results in a degradation of the quality of care to the patient unless the dentist is willing to settle for a higher overhead and a lower income. Few reputable and ethical dentists participate in these plans as well. As in all things economic, one main principle prevails in choosing dental plans: You get what you pay for! In many cases employees would be far better served by simply having their employers pay them the amount spent on their dental plan premium as wages, and allow them to make their own choices about who cares for them. There is now some progress in Congress to allow individual workers to start their own tax-exempt, medical savings plans.

Some patients feel that they absolutely have to have dental insurance. We definitely do not recommend an uninsured individual purchasing a dental plan on their own. Individual plans are far more expensive than group plans, and all dental insurance plans are carefully structured to virtually guarantee the insurance company a 20% - 30% profit of premiums over benefits. That means you will, over the long run, end up paying 30% more for your dental care than you would have if you had just paid the bill yourself. Under current tax law, you may not deduct the premiums from your personal income taxes the way an employer can, so there is no tax advantage to you.

In our office we have never compromised quality of care for economic issues. We have never belonged to an HMO plan and so far resisted PPO plans and State welfare as well. We believe firmly that all patients deserve the right to choose their own doctor. We also feel that it is unethical and simply unfair to charge different fees for the same procedure to different people depending upon their plan. Why should those without insurance or with traditional plans have to subsidize others with cheap plans? This attitude has undoubtedly cost us patients. There are, after all, some people who do not care about the quality of care they receive, or the record of and the credentials of the person treating them. The credentials of myself and my staff are a matter of record. We are fully dedicated to providing our patients with the uncompromised care that they deserve.