Dental Care Insurance...To Love or To Hate

Thomas K. Hedge D.D.S., F.A.C.E.
Pending Publication

Dentists have a love/hate relationship with dental insurance companies. It is nice that our patients have some help with their dental expenses. This benefit allows many people to participate in preventative and restorative dental care that otherwise could not afford to do so. However, the problems associated with this benefit can be time consuming and frustrating.

The first problem we encounter is that we never know how much they will pay for a procedure, their rational for the payment schedule, and if they have an exclusion for that procedure. Payment schedules vary greatly, and for no apparent reason. I pulled the information in the following chart from our database of past payments made by the insurance company’s representing eight major employers with Cincinnati dental care.

As you can see, Cincinnati dental care payments can vary by as much as 54 per cent in the case of the exam fee allowed by P & G versus Carolina Freight or Hoerchst Marion Merrill Dow. Isn’t it interesting that a company that sells preventative oral care products has the poorest coverage in preventative dental care?

Many insurance companies base their payment schedule on a UCR fee. This stands for Usual, Customary, and Reasonable. This is supposed to be an average fee charged by practitioners in a given region. UCR figures provided by the various insurance companies appear in the chart above in parenthesis. If, by definition, a UCR fee is an average, then how can it be different in a given area? How can $460 and $640, the UCR fee’s for UPS and Carolina Freight be so different for the same average fee charged by a practitioner in our area? When you call to inquire how they came up with their UCR fee’s, their answer is that it is confidential.

Companies like GE and P&G do not play the UCR game. They simply have a set fee schedule that they will pay on each dental care procedure. These fees are published in a benefits booklet given to all employees. Although the coverage does not appear to be as good, at least the insured know what to expect with respect to dental care coverage.

P&G’s fee schedule applies to the entire nation. There is no allowance for higher costs of living in certain geographical regions. This type of coverage is advantageous to patients in rural areas with lower fees. Patients in large metropolitan areas can be in for a big surprise as to the discrepancy between their dentist’s fees and their insurance allowance.

GE’s fee schedule is subdivided into three separate schedules denoted as A,B and C. The C schedule allows considerably higher fees than does the A schedule with B in the middle. For example, the C schedule will pay $253 versus $346 for the A schedule. This is 37 % higher. Each geographic region or large metropolitan area is assigned one of these fee schedules. On the surface, this system appears to be much more equitable than the P&G system, allowing for geographical variations in fees. The state of Ohio has all three schedules depending on what part of the state you are in. I know that Cincinnati dental care fees as well as those in Cleveland and Columbus are higher than in rural and outlying areas. I have friends in all three cities and I know that our fees are on par with one another. The GE, dental care insurance plan has assigned Cleveland the C schedule, northern Ohio the B schedule, and the rest of the state the A schedule. The only explanation for this that I can come up with is that there must have been a dentist from Cleveland on the committee that decided how to assign the state of Ohio. This is yet another instance of there being no "rhyme or reason" to an insurance payment schedule.

The biggest problem with insurance companies and their payment schedules is that they often imply either directly or indirectly that their insured’s dental care coverage is excellent and should cover all of their needs. If these expectations are not met, it is assumed by the patient that the dentists fee’s are too high. It amazes me of the number of new patients that enter my office with the expectation that their insurance will cover everything. This sets us up to be the "bad guy" by having to explain to them the reality of the situation.

This sets up a strong argument for the adoption of Direct Reimbursement plans where companies set aside a pool of funds, equivalent to their dental insurance premiums, that is made available to employees as a reimbursement of dental care fees that they have incurred out of their own pocket. This allows the employee or consumer of dental care services to decide on what and with whom to spend their dental care dollars. There is no insurance company in the middle consuming any of these dental care dollars and telling the consumer who they can see and how much they can spend on a procedure. This is a concept that makes so much sense that there is no valid argument against it, yet, few companies operate this way.

I would encourage everyone to be proactive when it comes to questions about their dental insurance and "just ask Why?!"