But I Have Dental Insurance

It should come as no surprise that the insurance industry is out to make a profit. It’s a business just like any other business. Any place an insurance company can cut costs or deny a claim is more of a profit to them and that is their goal. Unfortunately, this is not always in the best interest of the patient.

When my son was born 15 years ago he could not keep anything in his stomach. We went through a battery of tests to determine the problem. Not once did I think, “I wonder if the insurance is going to cover this?” When the diagnosis was made and it was determined that surgery was needed when he was only 10 days old, not once did I think to check with the insurance company to see if it would be covered. When all was said and done the insurance company said that we owed $10,000. I had the normal reaction that anyone would have – How could I owe $10,000 when I have insurance?

Dentistry is a little different. There are not too many situations where a life or death threatening has to be made or the dependency on insurance coverage needs to be assessed immediately. Many dental insurance companies suggest that a pre-determination of benefits be submitted prior to any work being done. The reason for this is to control what is being done and to delay the payment of a claim. The longer an insurance company delays a claim the longer they have their money and they know that longer time periods lead to the possibility of the patient not following through with the work.

I recently had a claim rejected by an insurance company for periodontal scaling and root planning (a.k.a. deep cleaning). This is a procedure done on people with periodontal disease to remove calculus (tartar) and bacteria below the gum level. The claim was submitted with the necessary documentation showing clear evidence (in my professional opinion) of periodontal disease and the need for treatment. What does this say to the patient? The patient put trust in the doctor to make the diagnosis and suggest the necessary treatment but the insurance company basically said that the treatment wasn’t needed. Not needed? How do you explain that to a patient?

What happens if I say, “Your insurance company said that you do not need this procedure, so I guess you don’t need it?” Two things happen. One is that the patient does not get the treatment needed, determined by someone sitting behind a desk who has never even seen the patient. The other is a huge increase in liability. When the patient’s periodontal disease continues and the person ends up losing teeth, who is responsible? You would logically think that it would be the insurance company who denied the treatment. This is not the case. The ultimate liability falls on the dentist for not managing the disease.

Patients need to be educated on their conditions. We live in an insurance dependent world. Just remember – your insurance company doesn’t care about you the same way your doctor does.