"While taking advantage of your dental insurance may help you feel like you're not leaving money on the table, it's still only one piece of the puzzle when it comes to your investment"

Introduction:

Imagine this scenario: you're in need of dental implants, and you call a dental office to ask about their services. One of the first questions you ask is, "Do you accept my dental insurance?"  The response you’re expecting may be a simple “yes” or “no.” And your decision to stay on the call may depend on a “yes.”  But if the reason you’re asking is to make sure you minimize the amount of money you have to pay out of pocket, it may be worth getting a more informed answer.

This article explores three of the most common misconceptions surrounding dental insurance coverage for dental implants.  Also highlighted will be the questions you should ask before and during a consultation with a dental implant specialist who may or may not take your insurance.  Let’s start with the first misconception.

1. My coverage is the same for all procedures.

This is a common misconception for insurance holders and is easy to embrace.  When comparing dental plans, there’s so much information to sort through that it’s completely normal to try and boil it down to just a few key numbers.  Coverage rates, deductibles, monthly premiums and copays are the most common.  When reviewing these, make sure that you inquire about how these numbers break down for different types of procedures.

For example, your dentist recommends x-rays as part of your routine check-up. You remember seeing in the insurance literature that your coverage is 100%.  So you don't pay anything out of pocket for the x-rays.  Great!  Just as you expected. A few months later, you develop a severe toothache and need a root canal or dental implant. You assume your dental insurance will cover the cost just like it did with the x-rays on the first visit, but you're surprised to find out that you have to pay a significant portion of the bill out of pocket because root canals and implants are considered a restorative procedure and are subject to different coverage terms.

Another example: You finally decide it’s time to replace the tooth you’ve been missing for the past five years, and you don’t want to put it off because you’ve noticed adjacent teeth have been shifting.  You discover that your plan has what’s called a “missing tooth clause.”  The clause states there is no coverage for your procedure because you were missing that tooth prior to signing up for insurance.  This is only one type of pre-existing condition that may exempt you from coverage and now you have to pay a significant portion out of pocket.  

To avoid this common misconception, get a clear view of all the different coverage percentages and terms-by procedure, if possible.  For starters, you should ask, “What treatments, precisely, are considered preventative treatment?  What procedures are considered restorative?”  These terms may be the same regardless of the dentist you choose.  Don’t assume they’re defined universally, however.  When it comes to how your insurance defines them, just make sure “apples are apples and not oranges.” 

2. My dental coverage is just like my medical coverage.

Dental insurance is often more restrictive than your medical coverage. Confusion about this happens all the time.  Your dentist quotes the cost of an all-on-four implant solution at $17,000 per arch.  “Thank goodness my insurance covers 50%,” you think.  But it’s only later you find out that your coverage is limited by a maximum threshold of only $2,000 total per year, leaving you with at best a $15,000 price tag.  On top of that, just hope the entire treatment is eligible, not just a few procedures within the treatment that aren’t restricted by your insurance.  What starts as relief can turn into frustration as it seems more like using a coupon at a grocery check-out line than insurance.

As a rule of thumb, and you can verify this by taking the time to do your own research, coverage for dental implants will range between 30% and 70%, with most falling right at 50%.  This is almost always still subject to yearly maximums that range between $1,500 and $3,000 with most landing right at $2,000 per year.

If you think that’s a fair discount, consider what some of the most reputable dental implant specialists are doing.  Often fee-for-service, meaning that they require payment in full prior to scheduling your surgery,  some of these practices offer discounts that can either closely match or exceed your dental coverage if you pay on the day of your new patient consultation.  The best part?  You don’t have to wait for insurance procedure pre-approvals or waiting periods that could delay you from getting your treatment, while keeping you in a cloud of uncertainty, crossing your fingers that the planets align.

3. My dental claims process is as smooth as a freshly paved highway.

This is often the biggest let down according to most insurance holders. Most dental insurance plans often have waiting periods for dental implants. A waiting period is a specified period of time that must pass before certain benefits are available.  For example, a dental insurance plan may have a six-month waiting period for dental implant treatments.  This means that if a patient enrolls in the plan, they would have to wait six months before they can receive benefits for treatment. 

Common sense says that when your insurance benefits begin, coverage on claims should begin as well.  You pay your premiums, you get your benefits.  But that’s not always how it works.  You might find a plan that doesn’t have waiting periods, but such a plan would mean a much higher monthly premium.  

The frustrating thing about this is that often the people who need immediate work are ones who have just recently obtained insurance.  Waiting periods are designed to prevent people from enrolling in a plan, getting expensive procedures done, and then dropping the coverage.  While this may make sense for the pockets of insurance company shareholders, it can be deflating for the person who’s excited to finally have (and be paying for) “benefits.”

Before undergoing a dental implant procedure, some dental insurance plans also require pre-approvals or pre-authorizations. This process involves the dentist submitting a treatment plan to the insurance company for review.  The insurance company evaluates the treatment plan to determine if the procedure is medically necessary and meets the plan's criteria for coverage. This helps ensure that the treatment is appropriate and that the patient understands their coverage and potential costs. If the treatment is approved, the insurance company will provide an estimate of the coverage and any out-of-pocket costs the patient may incur. This allows the patient to make informed decisions about their dental care.

That this process may take a few weeks seems pretty straight forward as a concept, but what is it like in reality?  What has been your experience or the experience of people you know?  Between multiple insurance departments, the dental practice, and you, how reliable is the communication, accuracy and urgency of information on your behalf being transferred?  An assertive patient on the phone or through email may be the squeaky wheel that gets the grease, but is it worth the time and frustration of feeling like you have to quarterback your claim to the end zone?

Tips to considers when using your insurance for dental implants.

So the next time you ask a dental practice whether they take your dental insurance or not, don’t just end the call and move onto the next dentist if they don’t, be prepared for a meaningful conversation that will save you money by considering the following tips.

First, know your dental insurance:

• What is the coverage percentage, specifically for dental implants?  What is the annual maximum?

• Is every procedure in my treatment eligible for coverage?  What pre-authorizations are needed?

• Are there any waiting periods for dental implants?

• What is the time frame for each part of the claims process?  

• Do I have an assigned/dedicated representative that can be my point of contact?

Second, ask the dental provider:

• What is your process for submitting claims to my insurance?

• What financing options are available if I have good credit?

• What financing options are available if I have no credit?

• How does your cost compare to other dental providers?

• Do you offer any discounts when I agree to treatment?

Remember that the cost of your dental implant solution involves much more than the dollar amount covered by your dental insurance.  You’re investing in the best solution available and the best decision is an informed decision.  While taking advantage of your dental insurance may help you feel like you’re not leaving money on the table, it’s still only one piece of the puzzle when it comes to your investment.