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3 Facts You Might Not Know About Your Dental Insurance

February 8, 2021

As dental professionals, to be in-network is not about benefiting from dental insurance alone. It is crucial to know its types and, most importantly, to review the insurance contract.

This article will discuss the different types of dental insurance. Also, learn about the unexpected things to note about the insurance contract. Plus, discover how you could effectively communicate coverage policies to your patients.

Types of dental insurance

Before getting into what a dental insurance contract entails, first distinguish between the different types of dental insurance:

  1. PPO (Preferred Provider Organizations) is a mutual contract between a network of dental practitioners and insurance companies. Under this plan:
    *Patients are free to consult dentists outside their insurance network, but usually pay more.
    * Dentists must accept the maximum permissible charge according to the policy.
    A PPO plan comprises all in-network preventive care, but has co-payments for restorative operations.
  2. DHMO (Dental Health Maintenance Organizations) is where participating dentists have a certain amount prepaid monthly for each patient. They provide specific services covered in the policy for free or at a reduced cost. Usually, this plan does not reimburse the dentist or patient for individual services. It requires patients to receive treatment at the approved office to make use of a benefit.
  3. Direct Reimbursement is an insurance plan entirely funded by a company employer for their workers. This plan allows an employee to choose any dentist they prefer and reimburses the money used on dental treatments. Some employers may decide to refund after their staff paid for their dental work. Some may arrange to pay the dentist directly. However, the application of direct reimbursement benefits varies depending on the coverage of the policy.
  4. Discount Plans are not insurance policies per se, but discounts on dental fees. Patients pay the treatment expenses at the agreed rate of the policy, without filing claim forms. Initially, insurance companies sell these plans to individuals only. However, more dental practices purchase discount plans for their employees’ health care benefits.

Other insurance plans are also available, but those mentioned above are the most prevalent in the dental industry. The American Dental Associations (ADA) also provides guidelines for dental plans for your reference.

Dealing with the dental insurance contract

No matter what type of coverage policy you have, contracts are crucial.

Some dentists barely read contracts from cover to cover and neglect to study them. Most dental practitioners look only at the fee schedule and write-offs. But there are limitations that might be missed that will surprise later on.

Here are three necessary tips to know about dental insurance contract:

  1. The contract may change (multiple times) without prior notice. These modifications may involve the percentage of reduction in dental services or the agreement conditions. Changes are often at the discretion of the insurer.
  2. Next thing you know, the practice is transferred to another network. The insurance provider can transfer a practice to a new network without informing them. A typical scenario is when a practice suddenly has to apply a discount on a patient’s treatment whose network was initially out-of-network.
  3. There can be more contract limitations. Your insurance policy may hold more restrictions in due course other than write-offs. An example is limiting the treatment reimbursement, leading you to collect more from patients.

Insurance companies are neither a foe nor an ally; they are businesses making a profit. But insurers do not change the contract covertly. Instead, they send notices via mail or email, and it’s the doctor’s responsibility to check them.

However, to avoid future complications with insurance, here are a few must dos:

  • Keep the original contract. Even though new updates will arise, keeping the initial document helps keep track of further alterations.
  • Read those insurance letters. No matter if it’s a simple update sent via email or a letter via snail mail – read them. This may be the only avenue where an insurer can notify on anything related to a policy.
  • Keep those notices. Scan all hard copies of notices to keep a record of them on a computer. Also, print them and keep them in a place that’s easily accessible.

Other suggestions worthy of note:

  • Be knowledgeable about proposed treatment costs.
  • Answer financial questions satisfactorily before progressing with treatment.
  • Do not hesitate to ask questions to the provider.
  • Admit accountability for dental insurance contract, benefits, and balance regardless of coverage subsidies.
  • Always present up-to-date policy information to the patient.
  • Request a predetermination of benefits to check a patient’s eligibility for coverage. This is better than confirming the coverage over the phone, because there will be a paper trail.
  • Expect that insurers may not pay even when there is a predetermination of benefits.
  • Pay a balance after 90 days, despite having concerns with the insurance plan.

Helping your patients

Dental practitioners must also effectively communicate the coverage policies to patients. Doing so will help avoid problems and convey good customer service.

Here are some ways to effectively deal with patients about dental insurance policies:

  • Educate them. Have a conversation between the practice and patients about dental insurance policies. Providing brochures are also helpful. Explain the following:
    • What the policy is all about
    • What’s covered and what’s not
    • What the conditions of the contract are
  • Assist them with copayments. Co-payment collection methods may differ per practice. But no matter what the insurance plan is, patients should settle the co-payments during the first visit to avoid any possible problems. Be sure to mention this to patients before the co-payment deadline.
  • Become their advocate. Check patients’ coverage and assist them in making the most of their dental benefits. Help them in submitting their claims for the maximum entitled compensation they are entitled.

Assisting patients to learn more about dental insurance ensures that the practice won’t run into any issues in the future. This will help avoid complications and gain patient trust and loyalty.

Stay safe

Today, it’s vital to be cautious of possible violations that can significantly affect the practice. Read, understand, and safeguard the contract. Share the knowledge and essential details to patients and staff to avoid mistakes. The result: maximize the benefits of dental insurance.


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