Helping your patients understand dental insurance’s how and why is a challenge. Only some patients know who their insurance provider is, let alone what benefits they have or how benefits might apply to their account. Patients assume that dental insurance is the same as medical insurance.
If we are honest, understanding and explaining dental insurance can also be challenging for the dental team. It can feel as though reading EOBs is a foreign language, with different insurance providers speaking other dialects.
Thankfully, we have AADOM and a fantastic group of teachers and mentors to guide us through the insurance gauntlet. We must effectively translate this working knowledge to our patients to educate them about their conditions, which will increase treatment acceptance.
I have developed successful ways to interpret insurance for patients so they better understand how their benefits work. You may remember the quote from the movie Forrest Gump: “Life is like a box of chocolates.”
The following analogies are my dental parallels to that quote, and I hope you find them helpful.
Maximum and Dental Plan Differences
Your employer chooses the provider and the type of insurance plan.
Dental insurance is like a bucket, and the employer chooses the amount of benefit that fills each bucket.
Often, employers have a plan that fills the bucket with $1000.00 per year, others $2000.00, and even $3000.00 per year. The employee and the employer often share the cost of these benefits through premiums paid.
In most cases, the more significant the benefit to the subscriber or patient, the higher the premiums. It is advantageous for the employer to choose reduced benefits to lower costs, and employers often do this by picking from a menu of ala cart items.
One plan might offer coverage for fluoride treatments only once a year and only for children under a certain age. Still, others may cover fluoride twice yearly with no age limits.
Frequencies and limitations on treatment are >extremely specific to the employers’ choices. They can change without the patient’s awareness from plan year to plan year as employers look for a cost reduction.
Therefore, employers also choose the ladle that scoops the dollar amount allowed. Each member of the family gets a bucket of dental benefits. The insurance provider provides benefits from the bucket once the claims for services have been paid and processed. If an item is not a covered service under the chosen plan, no benefits are available in the patient’s bucket or account.
Once the bucket is empty within a calendar year, no more benefits are available until the bucket is refilled in the next period. Any charge after the bucket is empty becomes the patient’s full responsibility.
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Application and Distribution of Benefits
Most people understand how a coupon works.
Dental insurance is like a coupon. Coupons have limits, restrictions, and end dates. Dental insurance does as well.
Dental insurance or coupons often offer a free cleaning and x-rays, but they limit the amount and frequency. For example, dental cleanings are usually completed twice a benefit year or once every six months. If a dental purchase for a cleaning is outside of those parameters, the coupon would be void, and the patient is responsible for the associated charges. This analogy is simple and easily relatable for patients.
In the same way that coupons offer a percentage of payment of the price, dental insurance provides varying percentages of dental services.
Major treatments are often 50%; other restorative work, like fillings, might be applied at 60% or 80% or whatever percentage has been agreed upon by the employer and the insurance company. When a service is omitted from coverage by the employer, no coupon is applied, and, in some states, full fees can be charged.
Coupons are redeemed by having dental procedures done; the insurance company will then scoop the equivalent dollar amount from the bucket of benefits for those procedures if applicable.
Allowables
Dental Insurance is like a savings club card.
Allowable is the term insurance companies use to define the contracted prices agreed upon between the employer and the dental provider for services rendered. Dental Insurance sets allowables for dental fees like a savings club card.
If you have a membership card, aka your dental insurance, you get the applicable savings, which translates to a reduced fee schedule preset in the dentist’s contract. Non-members or uninsured patients would pay the full fee for dental services. This savings applies to most policies, even if the dental bucket is empty and there are no coupons to apply to the service.
When patients understand the how and why of their insurance, treatment acceptance increases, and confusion and billing pushback decrease. While navigating patients’ insurance may take longer on the front end, it is a true> service to help them make decisions and get the care they need.
About the Author
Beverly Kicinski, FAADOM
Beverly Kicinski is the operations manager at North Penn Pediatric Dental Associates outside of Philadelphia, Pennsylvania. She oversees fifty employees and the daily responsibilities of this growing multi-location practice, which includes pediatrics, orthodontics, and a pediatric laser center.
Bev’s passions include implementing systems to improve communication and enhance a positive and productive culture. She has been a member of AADOM since 2024 and received her Fellowship in 2023.
Her multi-tasking and systems mindset stems from her “on-the-ground training” while managing six children and coaching women’s high school volleyball.