Most dentists agree that dental insurance has created better access to care during the last 40 years. They might also agree that dental insurance is one of their largest sources of frustration in managing their practices and patients. With close to 40 years of experience as a private practicing dentist and having spent many of those years in leadership positions in organized dentistry, I admit that the confusion and inequity perpetrated by the insurance industry has occupied more of my time and energy than I’d ever thought possible.
The confusion begins with the misunderstanding that dental insurance is needed to achieve good oral health, when in reality consumers are buying insurance products that are nothing more than reimbursement plans. These plans have maximum amounts they’ll pay for care that hasn’t changed in more than 35 years, and for this reason the plans don’t reimburse enough to offset the current cost of dental care.
Lack of transparency
The array of dental plans available with varying designs, degrees of plan provisions, and restrictions, coupled with the lack of transparency, adds to the frustration. Why should so much of a dentist’s time and energy focus on educating patients about their dental insurance rather than on their oral health-care needs? As the American Dental Association looks at dental insurance reform, addressing this lack of transparency is crucial to enhancing the doctor-patient relationship.
The lack of transparency is best demonstrated in the bifurcated insurance system that exists. Is a plan self-insured or fully insured? Do the plan provisions follow state guidelines or federal guidelines? Patients certainly don’t know, and my experience in dental benefits and government affairs has demonstrated that most dentists don’t know either.
Self-insured vs. fully insured
The issue of self-insured versus fully insured leads to another frustration. Can a patient assign benefits to the dentist and if so, how will that benefit be paid? Fortunately, almost half of the states have provisions in the law that allow for assignment of benefits regardless of the dentist’s network affiliation, thanks to the efforts of political action and government affairs at the state associations. However, that may not be the case for self-funded plans, which are how most large employers manage their benefits.
Assuming state law allows for assignment of benefits, is the benefit paid with a check, electronic fund transfer, or a credit card? Accepting so called “virtual” credit card payments from a carrier results in a fee to the dentist and savings to the carrier. Once again, through the efforts of effective government affairs advocacy, some states have prevented carriers from limiting claim payments to only virtual credit cards. Dentists now have options on payment methods.
Nonduplication of benefits
When we talk about inequity and lack of fairness, I think of the nonduplication of benefits clause found in many dental plans. There are many confusing aspects of dental insurance. For many, coordination of benefits (COB) is at the top of that list. When I was chairperson of the New Jersey Dental Association’s Council on Dental Benefits, I gave a one-hour lecture on COB. By the time I was done, even I was still confused.