Facts about insurance

“We ask that you realize that we don’t work for an insurance company. Rather we work 100% for our patients. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract. However, the treatment we recommend and the fees we charge will always be based on your individual needs, not your insurance coverage.”
– SI Client

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Traditional, or indemnity is the first one. PPO – Preferrred provider organization is a second type. HMO- health maintanence (key word is maintance) organization is the third.

Most large insurance companies offer all three types of coverage, so a consumer has to be careful in choosing not so much a company, but a type of a plan. In my opinion, as professional dentist, and in a opinion of many other medical professionals, HMO, sometimes refered to as DMO-dental health maintance organization, work well only in a maintance of your dental health, and prevention of the decease, as it was designed on the first place. It has never been intended to treat moderate or severe cases. True, it does not have yearly maximums – major selling point of insurance brokers, but look closer at coverage. Does it cover posterior composite – white fillings on the back teeth? Most, if not all allow (!) least expensive service, which is silver. And if patient choose cosmetically pleasant restoration, one is responsible for the full fee charged by a dentist. Will your dentist be willing to provide you with the best choice of materials available? For example, will he or she invest in the best quality of porcelain for your front crowns (cups), or will one do a “standard” quality?

In general premiums for HMO type dental coverage are least expensive (second main selling point of insurance brokers, especially valuable for the employers), but is it a good value? One, which you, as a consumer, wants? Take a second, more careful, look.

PPO-preferred provider organization was designed to meet the public demand to control medical cost, just like HMO. What happens, if your neighbors recommended you the dentist they have been seen for years, and you have a PPO insurance? Just like in HMO, members of PPO are “encouraged” to see a panel dentist. But not like in HMO, they have a right to be treated by outside of panel dentist. In other words, they have more freedom. Doctor is being reimbursed for the services provided (not per capita/ per month basis, like in HMO), at about 70 or 80 % of usual and customary fees (they are called UCR fees). Also coverage is more restricted in comparison to indemnity insurance. Basically, PPO is a hybrid between HMO and traditional insurance. Example of a good PPO insurance company is Cigna, Aetna, or Delta. They are more liberal in coverage and reimburse the claim in appropriate time (by law it should be 30 days turn-a-round). A very poor is a Blue Cross. They reimburse for the dental services at 1993 (!) rate, and the service they provide needs a lot of improvement. Anecdotal story I can provide about a last one is that approximately a year ago I sent two insurance claims in the same envelope to Blue Cross. After about 30 days one of them got paid and another one was not. I called Blue Cross, and a representative told me that they “have never received a claim for that patient”. That can happen on occasion. With this company it happened once too often. It also happened that I remembered that claim that got paid and one that was not, were sent in the same envelope. Obviously, the claim was “misplaced” by insurance company.

Indemnity, or sometimes referred to as traditional insurance coverage, is the best as long as one will keep in mind that insurance was created to help us to pay for the bill, and not to cover it completely. It has its limitations. For example, bridge work usually is covered at 50%, not at 80% as some patients expect. On other hand, if patient desires white fillings on posterior teeth, most insurance companies will reimburse. Benefits in the plan are more broad- more services are covered. Claims usually are paid on time, and without hassle from the insurance. Some do cover even dental implants. Most important difference is the freedom . Patient can see any dentist of their choice, they are not tight up to any office.

There are two more coverage types exists, although they are not considered to be an insurance. Direct reimbursement is one. The principle of it is very simple. Patient sees the doctor, pays the bill, brings the receipt to the administration office at their work place, and is reimbursed by them. Taking care of the bill this way, insurance administration of the claim is completely eliminated, bringing direct saving of to a patient. Percentage of this type of coverage is steadily increase, but still is small. If you are a benefit administrator, or you know one at your place of work and the company is considering dental benefits, I would definitely encourage you to get more information about direct reimbursement from CDA (California Dental Association), and sign up for it.

Please visit “http://www.ada.org/public/faq/insurance.html” American Dental Association web site at ADA.org, where you can find additional information about dental insurance or read a great article “Time for a Dental Insurance Checkup” on the same subject, but exploring it in a greater detail at


Another great piece from Wall Street Journal is about new and expanded coverage, including implants: