Patient Information

These plans compensate the dentist based on his or her's usual, customary and reasonable fee (UCR). The maximum benefits runs about $1000 to $5000 per patient per year. Insurance benefits are usually divided into three main categories:

1. Preventive services covered at 100%(exams, cleanings, and x-rays),
2. Basic services (anterior tooth-colored restorations and silver mercury amalgams posterior restorations) at 80%
3. Major dental procedures (crowns, veneers, root canals, oral/periodontal surgery) at 50%

A few insurance plans require a deductible to be met every year which can range from $50. to $100. dollars per family member.

These plans are becoming the more common form of insurance because employers can reduce cost by lowering benefits and allowable maximum. They provide members with a list of participating dentists to choose from. The dentists on this list have agreed to accept lower than their normal customary fees ranging from 10% to over 50%. Without realizing, dentists that participate in the severely discounted plans can create a class system within their practice. Class "A" patients that reimburse their normal fee and Class "B" that do not.
Good news is that most of the better PPO plans do allow you to choose outside their "list" if you are willing to pay a higher co-pay.
Bad news is sometimes the insurance plans sound fantastic but without realizing it you sign up for a plan that forces you to go to a severely discounted dental office.

Do we not all want our family to be considered Class "A" patients and receive the best treatment that dentistry can provide?

It is important to realize that the dental plans that severely reduce dental compensation force dentists to make drastic changes just to financially survive. One of the biggest changes is time spent by the dentist. Time spent on a service in usually in direct proportion to the final quality of product or service being delivered. It would therefore be no surprise that if a dentist severely reduces his or her time that quality would suffer. Other issues could be that staff would be doing procedures that would normally be done by the dentist. The quality of materials used could also be lowered to offset the decreased compensation.

Do not be surprised when insurance companies are selling these kinds of plans to the employer or Human Resource department this reality is rarely if ever discussed. It is unfortunate that sometimes you literally have to use the plan to figure out exactly what they are going to pay.

These plans are what we call capitated or prepaid insurance, was designed to provide members with basic care at the lowest rate. I do not recommend this kind of plan period. Participating providers receive a monthly capitation check for patients assigned to the office. This amount is only a few dollars per month and is intended to offset the administrative costs. All too often DMO/HMOs expect the participating dentist to provide exams, cleanings, and x-rays no charge. There is usually no additional compensation from the insurance company for any dental services other than whatever the patient's co-pay is.

In my forty years, I have found the discount plans almost always wind up costing the patient the most in the long run.

Here is an example that I hope shows that reality. Auto Paint Shops routinely advertises wide range of prices for their different paint jobs. Should anyone really be surprised that as the price goes down the amount of time spent and quality of materials used would also have to be reduced as well. Everyone would understand that the lower priced paint jobs would not last as long and would not look as good as the more expensive jobs. But somehow dental insurance companies will somehow try to convince you that this will not happen with discounted dental plans. Time spent and materials used is always a big factor that determines the quality of the end product no matter what service is being provided. There is old saying "buyer beware" and I think it is critical that we properly educate ourselves to all the factors that determine true value and ultimate cost when it comes to your dental care being delivered.