Dealing with Dental Insurance: Exceeding the Annual Maximum and Denied Treatment

Ah, dental insurance.  Don’t you just love it?

Sure it can help people pay for their dental treatment, which is great.  But the main problem is that many patients think that dental insurance is the same as medical insurance.

The expectation with medical benefits is that all or most of the procedures done by their physicians will be covered in full with only a minor co-payment.  This is, of course, not the case with dental benefits.  Yet when a patient exceeds their annual maximum or has a procedure not covered, they may decide to not pursue treatment.  This is a terrible mentality to encourage.

Don’t let your staff say things like, “Well after that next crown you’ll exceed your annual maximum so we’ll have to wait to do the rest until next year,” or, “Your insurance rejected that implant abutment and crown, so the bridge will be cheaper for you.”

Those statements will train and reinforce your patients to only do what their insurance allows.  I became a dentist to provide excellent care to my patients, not to be at the beck and call of a company who could care less about my patients.

Whenever I encounter one of those situations, I take the time to remind my patient about what dental insurance really is.  This approach works whether you’re fee-for-service or on insurance plans.

In a prior post on case presentation, I discussed how the words we choose are critical to helping the patient understand the truth of the situation.

“I’m glad you have dental benefits!  Thanks to your employer, a company will give you a yearly allowance towards your dental care.  This works great for smaller items like cleanings and fillings.”

Then I either choose speech (1) or (2), depending on the scenario:

(1) If the patient is going to exceed their maximum:

“But when we need to do a lot of work in a year, we can’t let that company’s allowance prevent you from treating the rest of the disease in your mouth.  This can lead to more costly and unhealthy situations in the future.”

 

(2) If the patient requires treatment that was denied:

“But when you need more sophisticated treatment to solve your dental problems, some companies won’t cover those procedures.  It’s a business decision with the company’s profits in mind, not a health care decision with your well being in mind.

“If we let the company determine your dental care, we may not like where that takes us.  It can lead to procedures that cost less now, but cost more in the future.  And these less ideal procedures can have cosmetic and functional drawbacks that make you unhappy.  Let’s talk about the pros and cons of all of our options.”

Notice that I refer to their dental coverage as “benefits” and not “insurance.”  This helps reinforce the idea that they should not expect full or majority coverage on all of their treatment.

If it sounds like I’m painting a picture of the insurance company as being an evil corporate business, it’s because I totally am.  I believe everything I wrote in the paragraphs above.

Pictured: A Dental Insurance Company's Board of Directors

Don’t let your patients adopt the mentality that a company should dictate their treatment!  If finances are an obstacle, offer payment plans.  You must maintain the vision of you and your patient in the driver’s seat.  Use a metaphor just like that one.  For example:

“You’re in the driver’s seat on this journey and I’m along for the ride right beside you.  Your dental benefits company is like having a friend that chipped in some money for gas.  Just because they help pay for the trip doesn’t mean they get to choose where we go!”

 

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Please note that I can no longer answer questions from the public regarding their personal dental care. I am unable to properly diagnose or recommend treatment over the Internet. If you are looking for a dentist, please visit the "Find A Dentist" feature on healthysmiles.org