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Predeterminations: how dental insurance companies save money…for the dental insurance companies(part 1)

Dental insurance companies make a LOT of money.  Even the non-profits.  The way that they do this is to pay out less in dental treatment than they take in from patient premiums.  Their goal is to take in more in premiums from their average subscriber than they pay out in dental fees.  There are a lot of tricks the dental insurance companies can use to create patient incentives to limit dental treatment.  The strategy I’m going to talk about in this post is “the predetermination.”

As a dentist, I’m excited by all of the cool and innovative treatment options that I can offer patients. Patients are sometimes excited by treatment options, but usually have concerns over the costs of treatment.

Let’s say I diagnose a failing filling with a new cavity underneath it.  I recommend that the patient restore this tooth with a crown before the decay gets any larger and causes a need for more extensive treatment (like a root canal, or worse…loss of the tooth).  The patient has to work through several concerns before they go ahead with treatment:

  • How much time will it take?
  • Can they work it into their schedule?  If so, when?  Will they need to arrange different rides for the kids’ soccer and football practices?
  • Will it hurt?
  • How much will it cost?  Will the insurance that they take money out of my check for help pay for it?

Often, my office team can help explain the procedure well enough and arrange the timing conveniently enough that it comes down to the $$$.  Kathy does an amazing job at predicting if insurance will cover treatments and how much.  But the insurance companies make it as difficult as possible for us to guess.   Often the patient wants to get a “guaranteed predetermination” of how much will be covered.  This is a huge opportunity for the insurance companies to save money for themselves.

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First, a predetermination takes time.  Even though we are completely connected via the internet, the insurance companies like to take a couple weeks to get back to the patient.  By this time the patient has long since forgotten about the decay (which is usually painless while it’s growing) under their filling and the patient didn’t make an appointment for the crown.

By making the patient wait for the estimate of how much the insurance company will pay for their specific treatment the insurance company keeps a certain percentage of patients from going ahead with treatment.

How do I know this?  I see patients every day that I’ve discussed treatment with who “slipped through the cracks” and didn’t complete treatment at the time we diagnosed a need.  Sometimes the timing wasn’t convenient for the patient, but often we have a copy of the “predetermination” sitting in the chart but no appointment was made.  This is the plan of the insurance company…and it often works.

Adding insult to injury…predeterminations aren’t binding.  If you read the fine print, in most cases the insurance can still choose to not cover the treatment.  I’m not going to say that happens often, but it can.

So, what’s the solution?

1) Make sure you trust your dentist’s opinion and that you believe they have your best interest at heart.  If you believe your dentist is trying to push treatment on you for financial gain you need to ask the dentist more questions or find another dentist.  Your dentist shouldn’t be annoyed when you ask questions…they should rise to the challenge!  It’s great if you trust your dentist’s judgement on their word alone, but they should be able to show you what they mean and explain all the treatment options, even doing no treatment.  If they balk at this…you should get a second opinion.

2) Make an appointment.  Kathy and/or Shelly can usually guess when any predetermination will arrive via the mail as well as a rough estimate of your out of pocket costs for most treatment.  Make your appointment for a couple of days after this.  By that time we can discuss any concerns you have and change our plans if necessary.  But at least you won’t have fallen through the cracks.

Questions or comments?  Email me at alan@meadfamilydental.com.  I read and answer all of my own email and I’m always glad to hear from patients and prospective patients alike!  Also, keep checking back for the other parts to this series on dental insurance!  Part 2 will be published here.