Austin Smile Creations – Austin Dentist Blog

A blog about implant dentistry, cosmetic dentistry, general and family dentistry and a healthy living.

Archive for dental coverage

Dental Insurance. In and out-of-network providers.

This is a very complicated topic. The intricacies of the insurance system and variables in dental practices make it very complicated to explain, but we will try to share some insights into the world of insurance confusion.
It is a fact that dental insurance is nothing like medical, and you should keep that in mind. The coverage is very different, and there is nothing that dental insurance realistically covers at 100%. Most PPO plans state that they pay 100% of preventive services ( cleanings and exams), 80% of basic services ( fillings) and 50% of major ( everything else). There are some variations in which services fall into which group based on the plan. It is important to know that they pay percentages of their “usual and customary fees” which they define based on some national averages. Also keep in mind that these fees have not been updated for 15 years or so, so do your own math and figure what realistically the payment can amount to, especially if you live in a prominent area, say, such as Westlake Hills in Austin. Another important thing – the yearly maximum that insurance pays on most plans is $1500. While it is better than nothing – it will not help you tremendously if you need a lot of dental work and you need it done in one year. Insurance does not cover TMJ disorder treatment, cosmetic services, implants. Most insurance agents offering better policies do not sell dental insurance at all. So it is up to you to make a choice if dental insurance is worth the premiums for you for these benefits.

It is also a fact that there is a difference between in-network providers and out-of-network providers. While most people don’t realize it, no two dental practices are the same, even without any affiliations with insurance networks. Every dentist is different when it comes to education and experience, has a different approach to dentistry, chooses different equipment and materials, techniques and methods, and also how to run their business. When it comes to determining fees –  all of those factors plus the going rates in the area where the practice is located are crucial. Knowing that, even if you do shop around, you will probably not find a big difference comparing fees of dental practices of similar philosophy. If you find a big difference –  odds are – you are comparing apples and oranges and you may want to ask yourself what that difference gives you and what you might be sacrificing by choosing one practice over the other.

With in- network providers, the insurance company and your employer negotiate the rates and what is covered. So the insurance companies set their level of reimbursements to the doctors for various procedures and the rest of it is your out-of-pocket. Unfortunately, because of being very outdated ( ask any insurance agent) – the reimbursement rates are very low, and the doctors who strive to produce cutting-edge dentistry using the latest equipment simply cannot make it work, otherwise there would be no out-of -network providers. There is a reason why many dental practices choose to be independent –  so they could be the ones setting the bar for themselves. And even then, there are apples and oranges.

Hopefully this helps you a little bit to understand the big picture ( or at least see that it is even bigger). We believe, that one factor in determining your choice of a dentist trumps all others -it  is not insurance, not if the dentist is in- or  out-of-network, but the dentist himself.  The level of continued education, experience, desire to stay current with technology, and if you can trust him or her is what will help you get your money’s worth and get many more benefits in the long run. You want to develop a relationship with your doctor that will help you achieve and maintain your oral health for a lifetime, not just for the time of your appointment. And that is what we do every day and love it!