Dental Insurance: A Love Story

Dental Insurance: A Love Story

If you know me or have been a patient of mine, you might have heard me go off on a tangent about the shortfalls of dental insurance.  While certainly, they tend to jack up my blood pressure, a part of me is very thankful for these policies.  If they only had better “customer service”, maybe I wouldn’t rant as much as I do.

Here’s the deal.  Dental Insurance is not true insurance.  It is a BENEFIT.  Now copy down those last two sentences on a piece of paper, take it to a mirror, and repeat those lines 10 times.  Ok, maybe you don’t have to go that far with it, but I’m trying to get my point across.  Dental “insurance” is a benefit program, usually offered by your employer.  And it’s your employer that chooses what “insurance” company they go with and what PLAN they want to provide.  There are numerous “insurance” companies, and each company has countless numbers of plans.  And each plan has different services that are covered, and how much they will cover for those procedures.  And a lot of times, the employer is looking to spend as little as possible.

To outline this, here are some sample benefit plans I’ve seen on patients.  These are all through the same “insurance” company, but each plan is dramatically different:

*(Any Provider) means no matter if the doctor is in-network or out of network, they will pay the same.  These plans are becoming exceedingly rare, unfortunately.

Plan 1:  $1500 yearly benefit, no deductible

2 exams a year covered at 100% (Any Provider)

2 prophylaxis (ie basic) cleanings a year covered at 100% (Any provider)

Fillings (both White and Silver) covered 100% (Any provider)

Root Canals covered at 80% (Any Provider)

Extraction covered at 80% (Any Provider)

Crowns, Bridges, and Dentures covered at 50% (Any Provider)

AND a $1500 orthodontic benefit given one time to the patient, i.e. NOT renewed yearly

Overall, Plan 1 is a very nice plan.   It doesn’t limit the patient’s options on what office they go to.  The office gets a reimbursement set at their fee schedule.  Everybody wins, except for maybe the “insurance” company.  Because the more money that they payout, the less money they get to keep.  And it’s because of THAT reason, that these companies have started dwindling down the services covered, and the yearly benefit amount.  An example of this is Plan 2.

Plan 2:   $1000 yearly benefit, $100 deductible

Fillings (silver or white) covered at 50% a year (any provider)

Root Canals covered at 50% (any provider)

Extractions covered at 50% (any provider)

Crowns, Bridges, and Dentures not covered

No Ortho Benefit

As you see, Plan 2 is a pretty significant cut to the number of services covered, and what percentage they will pay.  The only silver lining here is that you can still go to any doctor you want.  To save the insurance company even more money, they have negotiated fee schedules for “IN-NETWORK” (or PPO) offices.  This means that the “insurance” company has come up with caps on what an in-network dentist can charge for the procedure.  So if the dentist’s regular fee for a basic cleaning is $70, the insurance company only allows the dentist to charge $45 dollars for a cleaning.  That might sound great, but depending on the dentist’s office and their overhead, a 35% reduction in fee might not be very feasible.  And that leads us to Plan 3:

*Note that on the insurance card, instead of PPO it may say “UCR” or “UCF”

Plan 3:  $1000 yearly benefit, $0 deductible

2 exams a year covered at 100% of the company’s PPO rate (any provider)

2 Basic cleanings a year covered at 100% of the company’s PPO rate (any provider)

Fillings (silver or white) covered at 80% of the company’s PPO rate (any provider)

Root canals covered at 80% of the company’s PPO rate (any provider)

Crown and Bridge covered at 50% of the company’s PPO rate (any provider)


The good thing about this plan is that you can go to any provider you want.  However, how much you will pay out of pocket can be different between whether or not you go to an in-network office.  So let’s break this down further:

The company’s PPO rate for a new patient exam ($40), basic cleaning ($45), Full-mouth X-rays ($99), and Topical fluoride treatment ($15) comes out to a total of $199.  So if you go to an in-network dentist, you won’t have to pay anything on this plan.

HOWEVER, if you go to a dentist who accepts that insurance and will file it for you, but is NOT in-network, your out-of-pocket expense might be higher.  In the above example, the company will pay 100% of their PPO rate, which comes out to $199.  Well if the dentist’s rates are different from the company’s PPO rates, there will be a difference.  For example, the dentist’s regular fee for a new patient exam ($70), basic cleaning ($70), Full-mouth X-rays ($130), and Topical fluoride treatment ($28) comes out to a total of $298.  So that means you would have an out-of-pocket amount of $99.

I know what you are probably thinking.  Why in the world would I go to an out-of-network office when I can go to an in-network doc for free?  Well, this is a very personal question and one that I can’t give a definite answer for, but here are some examples.  First off is if it is a dentist you actually like.  Let’s face it; most people aren’t super stoked about going to the dentist.  But if you find one that you like, has a good chairside manner, and you find personable, it might be worth spending a little extra to be seen by someone you trust and feel comfortable with.

Another reason is the quality of technologies and materials.  High-quality materials and technologies (i.e. digital x-rays, great filling materials, using good labs for crowns, etc) cost money.  Some offices can still offer these at low prices, and some can’t.  This can depend on what area in the country you are in.  It can depend on whether they buy new and used equipment.  And it can depend on when the doctor graduated.  New dental graduates are leaving school with $300K+ in professional student loans at around 8% interest.  This person’s situation is a lot different from what a doctor who graduated 30 years ago and has been student loan-free for decades.  As you can see, there are a lot of variables that come into play here.

Lastly, another reason one might prefer paying more out of pocket is convenience or less need to travel.  People will spend $40 dollars in gas, take extra time off of work (and if you don’t get paid time off, this really racks up the expense) to drive to an in-network dentist to save $20 on their lab bill.  This is more prevalent in rural areas than metropolitan areas.

And be forewarned, dental “insurance” companies are starting to tighten the belt even more with plans that ONLY payout if you go to an in-network provider.  Fortunately, these aren’t too common… YET.

Another interesting fact about dental insurance is that when it started back in the 1970s, the yearly benefit was about $1000.  And guess what!  Nearly 40 years later, that still hasn’t changed.  Back in the day, you could get A LOT of stuff done for $1000!  Now, dental “insurance” is known as the “Tooth of the Year” club.  If a tooth breaks or has a very bad cavity, it may need a root canal, build-up, and a crown.  The total fee for that is going to be around $1500 or more.  Well, I guess you’re maxed out for this year.  That $1000 benefit in 1974, adjusted for inflation, should be $4592 today.

But that’s not my biggest beef with dental “insurance”.  What boils my blood the most is when someone has a benefit, a doctor has rendered a treatment that is clinically acceptable and is covered on that patient’s benefit, and yet the “insurance” company STILL denies payment.  That to me is unacceptable.  The “insurance” company is not a doctor, they are not there with the patient doing the work, they do not have the clinical knowledge and training to make treatment decisions, so what gives them the right to deny payment for services rendered?  Because they are covered by politicians by anti-trust laws, return more money to their investors by denying coverage and claims, and really aren’t held to the standards of customer service to you or I.  Your employer bought this benefit, you didn’t.  So for them to take notice, it takes the employer raising a fuss to the insurance company, which isn’t realistic in many cases.

Now, I don’t want this article to come across as a hate letter about dental “insurance”.  I actually think these benefits can be a great service for people.  And if you have dental BENEFITS, by all means, use them.  But beware, they like to play games.  Also, they don’t want to pay.  And sometimes they will blatantly lie to the patient, doctor, or both.  I’ve heard many recorded conversations with dental “insurance” reps lie or falsify information about a patient’s coverage.  It’s no wonder why many dentists shy away from these plans like the plague.  At the end of the day, it behooves you to do your homework about YOUR benefits. It is impossible for any dental office to know the ins and outs of every plan there is out there. The more knowledgeable you are, the more leverage and control you have over your dental health.

P.S.  There are a couple of great blog posts by Dr. Alan Mead (one of my favorite dental bloggers) pertaining to dental “Insurance” that I highly recommend checking out:



More Options for Straight Teeth!

More Options for Straight Teeth!

Great news! As most of you know, I’ve been getting started with Powerprox Six Month Adult Braces for adults looking for straight teeth in a reasonable amount of time. Well, we’re expanding our orthodontic services EVEN MORE!!! Soon we will be offered CLEAR BRACES as well!! These are a series of clear trays that move the teeth and give a great smile. And…. that’s not all. Just today I signed up with a comprehensive orthodontic training program so we can start offering braces and appliances for older KIDS and TEENAGERS. My goal is to be able to treat 80% of the cases that walk in the door. How cool would it be to not have to drive an hour away just to get a bracket rebonded??? Now that’s service!

No Need for the Hard Sell

No Need for the Hard Sell

I’ve heard from a few patients that they’re surprised that I haven’t tried to “sell” them anything and that it’s a great relief. I am very pleased to hear this. I think dentistry has gotten a bad rep over the last decade, definitely as concerning with overtreatment. Well, I can assure you at Eureka Family Dental, we don’t try to hard-sell treatment. I evaluate the case, diagnose, educate you on what’s going on, and give my opinion on treatment options.

If that tooth that has an old silver filling shows signs of cracking, I’m going to take a picture of it, show it to you so you can see what I’m talking about. Then, depending on the situation, I’m probably going to recommend replacing the filling, or if that won’t work, reinforcing that tooth with a crown. That’s about it. I’m not going to go into this whole jargon-laden spiel about the physical properties of the material used during crown fabrication and how it is vastly superior to the tooth’s current condition (Don’t get me wrong, it is. But that’s not the point.) Instead, you’ll hear me make my recommendation, give you a brief reason why, and then you’ll be free to ask any questions if you have any. That’s about it. The reason why I do this is that, in all honesty, it doesn’t matter to me what you do. I hope this doesn’t come across as bullish, I’m just being honest. I want to offer the best care for people. But ultimately, it’s their decision if they want the treatment and if they’re willing to pay for it. And in reality, I believe treat more people BECAUSE of this.

No one wants to be “sold” something by someone who doesn’t have their own best interest at heart. And in my practice, I don’t see the need to. Sure, I offer things like implants, braces, and whitening. But I don’t try to “sell” it to people. I inform them of what services I offer, how it might help their situation, and that’s that.

Here is a video that (crudely) gets my point across. I think this commercial is very funny, and in a way, reflects my view on “selling”. So, if you’re looking for a dental office that won’t try to sell you on stuff you don’t need, but will be upfront and honest with you, then look no further.

The Only Constant is Change

The Only Constant is Change

There is a change of climate in all aspects of healthcare and dentistry is no exception. Insurances are raising their deductibles and lowering their coverage. Employers are decreasing or flat-out cutting benefits offered to employees. Politicians are crying out for solutions while beating their drums to the “access to care” battle cry. Inflation is still in full effect, and the spending power of savings is on a proportionate decline. Providers are facing lower reimbursement from insurance plans, even though the cost of materials/operating cost/general overhead is on the rise. Some states are passing midlevel Providers or what I like to call junior surgeons because “Hey, it’s JUST a filling”, even though it’s a surgery that takes the precise hand skills of jeweler or watchmaker, while working upside down and backward in a mirror, on organs located in a wet swamp of a mouth.

As Bob Dylan twang-fully sang in a way only he could pull off “The Times They Are a-Changin’”. And boy, are they ever. However, it’s not all doom and gloom. There are also very exciting things in dentistry (and medicine in general). One being technology. I can now take digital X-rays on a patient that require much less radiation than traditional film, and I can blow the image up fullscreen on a computer monitor, draw and highlight conditions, and show the patient clear as day. Sure beats pointing to a small film an inch wide on a view screen and expecting patients to understand. I can now take an actual close-up digital photograph of a cracked tooth and show the patient. Now the patient can see what I see, instead of just having to take my word for it. When trying to explain the progression and effects of periodontal disease, instead of trying to use overly technical jargon in my attempt to describe, I can just pull out an iPad, bring up a patient education app, and show the patient the progression of the disease through simple animations. Some offices can even make crowns right there in the office without the patient having to wear a temporary for two weeks (something I’d like to afford in my own office someday, but hey, baby steps right?).

Another aspect of dentistry that is very exciting to me as a clinician is the amount of knowledge and learning that is available. If I want to learn about a new product or material, I can sign into a webinar. If I want to learn a new skill, I can attend a curriculum that teaches that very skill, much like my education in orthodontics in Tulsa, OK.

All things considered though, the change that’s brewing that gives me the most hope in my profession is the growing desire for patient-centric care. More and more people are sick of being treated like cattle, and specific to dentistry, people don’t want their dental condition restored like the dentist is just fixing widgets. Don’t get me wrong, I am a BIG believer in systems. I believe proper systems increase efficiency, predictability, and if done right, quality. And for actual procedures, these systems can be a Godsend. However, the people that these procedures are being done are not cattle, and their bodies (or teeth, organs, etc) are not widgets. I believe a dental office should be a thriving business, but the McDonalds way of overly systemized low cost (and a lot of times low quality) might not be the best model. I mean, we ARE trying to promote health aren’t we? Is mimicking a business that, while cheap, is actually detrimental to health the answer for our patients and the public in general?

I would argue that uniformity is the enemy of the health of the public. Look at the USDA’s guidelines for the Standard American Diet (appropriately abbreviated as SAD), and its impacts on the health of the public since its inception in the 1970s. People’s weights have gone up, waistlines have increased, disease processes (diabetes, cardiovascular disease, cancer) have dramatically risen in just a few decades. Here’s the dirty little secret: People are different. No two people are the same. Some people can thrive on a moderation diet. Some folks do better with a plant-based/vegetarian/vegan lifestyle. Myself, I do best on a grain-free, lower carbohydrate diet. People are unique. So why would we not celebrate this fact and incorporate this into our practice and treatment models? In medicine, the direct-care and concierge models are dramatically on the rise. And ultimately, I believe this the next stage in the evolution of healthcare. The ironic thing about this is that it’s actually a return to a previous care model of sorts.

In the coming years, both doctors and patients are going to have to adapt. In the dental world, the whole “every person will have a 6-month cleaning and exam” will be no more. It will be much more specific to that patient’s needs. Some people will only need a routine cleaning every 9-12 months. If the patient has active inflammation or infection, they may need treatment every 3-4 months. Bitewing X-rays won’t be taken just because the earth has orbited one full revolution around the sun. They will be prescribed based on that patient’s needs, history, and current conditions. An example of this is a 22-year-old that has a previous history of 8 fillings from cavities in between the teeth, and with 3 current cavities also in between the teeth. This person should probably have Bitewing X-rays done every 6 months until his condition has stabilized because he is a high-risk patient for dental caries. However, if there is a 55-year-old woman with only 2 existing fillings, maybe a crown that looks to be in good shape, healthy pink gums, and hasn’t had a cavity in 20+ years, this is a very low-risk patient and could probably go 2 years before needing new Bitewing X-Rays.

So if you’re a doctor reading this, realize that change is on the horizon and start taking action steps to prepare and adapt. You may have to get out of your comfort zones a bit, and that’s perfectly fine. You can’t truly grow otherwise. And if you are a patient (especially one of MY patients), realize that things might be done a little differently in the near future. You may be asked a lot more questions, not to interview you per se, but to get a better grasp on YOUR current state of health and YOUR value systems. You may be asked to take more of a hands-on leadership role in your health, and to take the reigns with self-accountability. Take this opportunity to be empowered and to take charge of your own health. Nobody else can do it for you. Because nobody else is YOU.

This Country Needs a Better Diet, Not More Dentists

This Country Needs a Better Diet, Not More Dentists

Make no mistake; dental caries (aka cavities) are a disease. It is a degenerative disease of the teeth caused by bacteria. The 2000 Surgeon General’s report on “Oral Health in America” identified tooth decay as the most common chronic disease of children in the U.S. Dental caries is most prevalent in lower-income households. When folks read this, they usually throw their hands in the air and blame it as an “access to care” issue. Because of these reports, there has been a push by lobbyists and politicians (both state and federal alike) for a “mid-level provider” to increase this “access to care”. The purpose of this article is to shed some light on the issue, to advise where attention should really be given, and to give some suggestions on where to go from here.

First, a short science lesson is in order. We’ll call it “Cavity-ology 101”. The first lesson is a simple formula on which we’ll expand:

Teeth + Bacteria + Sugar +Time= Cavities

The mouth contains a wide variety of bacteria, but only a few specific types of bacteria have been found to cause cavities. It’s because of these select strands of bacteria that we have thousands upon thousands of kids with tooth decay. But how do these bacteria, which I like to call “bugs” due to better imagery, cause cavities exactly? Well, bacteria are constantly creating a layer, or biofilm, on your teeth. This biofilm becomes a sticky, creamy-colored mass most commonly known as plaque. In other words, that fuzzy stuff that collects on our teeth is a network of millions of bugs lining an assault. Their means of attack is by the production of acid. And the fuel source for these bugs to pump out acid is none other than sugar.

The harmful bacteria in our mouths convert sugars into acids through a process called fermentation. If allowed to sit on the teeth, these acids can cause the teeth to lose their strength by robbing them of minerals through a process cleverly called demineralization. With enough demineralization over time, the tooth “disintegrates” and is left with a hole or cavity. The scientific study of how sugars can affect the progression of cavities is called carcinogenicity. Without getting to jargon logged, let’s keep it simple. Different types of sugars are worse than others (i.e. table sugar is worse than sugar from fruit), but given enough time, most of these common sugars (sucrose, glucose, lactose, and fructose) can cause cavities. So it doesn’t matter if the sugar is from candy, pop, bread, milk, potato chips, juice, fruit, etc; they all will lead to cavities given enough time.

The next step on the road to cavities is time. How often teeth are exposed to sugar and acid plays a big role in the formation of cavities. After meals, snacks, or anytime you put fermentable sugar in your mouth, bacteria produce acid. Each exposure can dissolve your teeth for up to 2 hours. To help get this point across, let’s use an example. Jack and Jill don’t brush their teeth all day. Jill eats 3 times throughout the day: Breakfast, Lunch, and Dinner. Each one of these meals has a good amount of carbohydrate (sugar) content. This means that her teeth can be subject to acid attack for six hours in just that day alone. Now to make things worse, here comes Jack. Jack eats the same meals as Jill, but also has some potato chips for a mid-morning snack, and has a can of Coke a couple of hours after lunch. This means his teeth could be left dissolving for 10 hours (5 meals x 2 hours of acid)! And I won’t even go into what would happen if Jack were to nurse his Coke all day long.

There are other factors that can lead to cavities. These can include the quality of mineral content in your saliva, tobacco use, and rare developmental disorders of tooth formation. But for the vast majority of the population, cavities are the result of the combination of bacteria, sugar, and time. So where do we go from here? Well, the answer is painfully simple. Cut down on sugar and brush and floss more.

The End… for now

I have a lot more to write about the subject, and the paper is far from over. But here is a launching pad if you want to know how to protect your teeth for life-long service. As always, if you have any questions whatsoever, feel free to ask.