Confusion and inequity of dental insurance


Most dentists agree that dental insurance has created better access to care over the past 40 years. They might also agree that dental insurance is one of their biggest sources of frustration in managing their practice and their patients. With nearly 40 years of experience as a private practicing dentist and having spent many of those years in leadership positions in organized dentistry, I agree that the confusion and inequity perpetrated by the insurance industry took up more of my time and energy than I ever thought possible.

The confusion begins with the misunderstanding that dental insurance is necessary to achieve good oral health, when in reality consumers are buying insurance products that are nothing more than reimbursement plans. These plans have maximum amounts they will pay for care that have not changed in over 35 years, and for this reason the plans do not reimburse enough to offset the current cost of dental care.

Lack of transparency

The range of dental plans available with varying designs, degrees of provisions and restrictions, coupled with the lack of transparency, adds to the frustration. Why should a dentist’s time and energy spend so much time and energy educating patients about their dental insurance rather than their oral health needs? As the American Dental Association delves into dental insurance reform, addressing this lack of transparency is critical to improving the doctor-patient relationship.

The lack of transparency is best demonstrated in the bifurcated insurance system that exists. Is a plan self-insured or fully insured? Do the provisions of the plan follow state guidelines or federal guidelines? Patients certainly don’t know that, and my experience in dental benefits and government affairs has shown that most dentists don’t either.

Self-Insured vs. Fully Insured

The question of self-insurance versus full-insurance leads to another frustration. Can a patient assign benefits to the dentist and, if so, how will this benefit be paid? Fortunately, nearly half of the states have provisions in law that allow benefits to be awarded regardless of a dentist’s network affiliation, thanks to the efforts of the political action and government affairs associations of the state. However, this may not be the case for self-funded plans, which are how most large employers manage their benefits.

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Assuming state law permits the assignment of benefits, is the benefit paid for by check, electronic funds transfer, or credit card? Accepting so-called “virtual” credit card payments from an operator results in fees for the dentist and savings for the operator. Once again, through the efforts of effective government business defense, some states have prevented carriers from limiting claim payments to virtual credit cards only. Dentists now have options on payment methods.

Non-duplication of benefits

When we talk about inequity and lack of fairness, I think of the non-duplication of benefits clause found in many dental plans. There are many confusing aspects of dental insurance. For many, Coordination of Benefits (COB) is at the top of the list. When I was chairman of the Council on Dental Benefits of the New Jersey Dental Association, I gave a one-hour talk on COB. By the time I was done, even I was still confused.

Patients are led to believe that by paying two premiums and having two dental plans, they are entitled to all the benefits of each plan. Sometimes they are, but in most cases they are not. This single regimen arrangement has resulted in more patient confusion and misunderstanding than probably any other arrangement. Patients should be informed of plan provisions before purchasing a plan and should be entitled to their full benefits after reasonable and fair coordination of benefits. Carriers claim that non-duplication clauses prevent the insured from being enriched by the plan when in fact this provision adds to the cost savings and profitability of the carrier.

Network rental

A recent challenge that dentists who participate in dental plans have faced in recent years is the sale or lease of their networks by dental insurers. Over 35 years ago, I became a provider on a discount insurance plan that after two years had very few patients. Due to lack of activity, I assumed the plan had ceased to exist. Two years ago, I was told by patients who worked for the New Jersey state government that I was now part of their network, although my office was never involved in the plan. State or one of the carriers with which they had contracted.

Much to my dismay, after investigating, I discovered that the carrier that had the New Jersey state contract had purchased the network from the company that I assumed no longer exists. Afterwards, it took me three months and thousands of dollars to get out of a contract that I didn’t even know was in effect. It interfered with my patients’ relationship, which took months to mend. I had to launch a marketing campaign to correct the miscommunication and misunderstanding the insurer had created for my patients. Since leased network legislation was passed in New Jersey, this will not happen again. Carriers are required to provide sufficient notice and to give the dentist the opportunity to opt out of the rental offer from the network and to do so without affecting the original contractual relationship.

Dental insurance reform

As Chairman of the ADA Council on Government Affairs, I realize how many dentists are working at the state and federal level to effect dental insurance reform. Each of the successes has led to less confusion and inequity in dental insurance. A good example is uncovered services.

The current dental insurance landscape is unfair to both providers and patients. Dentists, their patients and the general public are disadvantaged by the negative impact that the provision of uncovered services has on competition between entities in the health insurance industry. Imposing discounts on providers for services that an insurance company does not cover is a marketing ploy designed to gain a competitive advantage over smaller carriers. It also acts to hinder the doctor-patient relationship and can shift costs to the uninsured.

At the federal level, the ADA has advocated for the Dental and Optometric Care Access Act. This will prevent insurers from requiring dentists to pay fees for services they do not cover and from providing unreasonably minimal compensation for services rendered. The ADA has been pushing this bill for more than two years. While this legislation would affect self-insured plans, state dental associations have been working on legislation to affect fully insured plans. To date, more than 40 states have passed legislation that prevents carriers from charging fees for uncovered services. If the uncovered services campaign was a constitutional amendment, it would have already been ratified.

Coding confusion

Speaking of confusion and unfairness, one cannot forget under-coding, bundling and prohibited services. Undercoding and bundling creates enormous confusion for patients and can create a lack of trust in their dentist. When an operator discounts (replaces a fee with a lower cost service) or bundles (bundles services with separate fees into one fee), patients perceive that the dentist or office staff has done something wrong.

“Refusing” dental treatments is questionable because the plans do not use the diagnostic and patient preference information that the physician used to make the treatment recommendation to conclude their denial/refusal. These are unfair business practices on the part of the dental payer industry whose objective appears to be to reduce the cost of claims rather than to optimize patient outcomes. Commercial financial targets set by insurance companies interfere with the patient’s access to appropriate and necessary care, and this is unfair to the recipient and purchaser of benefits. We could argue that this borders on unethical business practices.

One way to minimize confusion and inequity in a dental practice is to implement an in-office patient enrollment and retention plan. This was particularly appreciated by patients who assumed they needed insurance to visit the dentist. These plans also provide an effective way to help patients who want to stay in a practice despite financial hardship.

The maze of dental insurance can be daunting for patients, dentists and members of the dental team. The best way to minimize confusion and inequity is for dentists to educate themselves so they can educate team members and patients. Dentists taking an active role in organized dentistry and advocating for insurance reform are key to reducing confusion and inequity.

The ADA has a program called Third Party Concierge that helps dentists resolve their issues with dental insurance companies. ADA members can call or email a Designated Expert for insurance-related questions and concerns. Check out the ADA’s online hub for the latest dental insurance information to help you understand the nuances of doing business with dental insurance companies.

Editor’s note: This article originally appeared in the June 2022 print edition of Dental economy magazine. Dentists in North America can take advantage of a free print subscription. Register here.


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