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Browsing 13 posts in medicine and dentistry.

Yearly maximums: how dental insurance companies save money…for the dental insurance companies (part 2)

This is the second installment I'm writing about dental insurance.  The first one is here.  I'm fascinated by medical insurance.  I'm fascinated by "health insurance reform."  Am I fascinated by dental insurance?  No.  Not at all.  Mostly annoyed, really.

I have to admit that there are probably a lot of teeth that have been saved by dental insurance.  But the incentives that it sets up for patients are damaging in a similar way. Delta Dental pond

(Delta Dental of Michigan's headquarters—–>)

Nice pond!

Let's say a patient has stayed away from dental treatment for a lot of years "because they didn't have dental insurance."  Unfortunately, this is an everyday occurrence.  They may have a lot of different dental problems from years of neglect.  They might have decayed or fractured teeth, gum problems or missing teeth.  They're excited to get in and use their new dental benefits and get back to dental health.  They have a yearly maximum benefit of $x that they can put toward this dental care.

After examining the patient and diagnosing their dental situation we find that the patient needs $4x of dental work.   W796dollar-sign-1981-posters

So their dental insurance might cover 25% of the cost of their needed treatment and they've decided that they don't have extra money outside of what their insurance will cover.  What does this do?

  • First, it makes the patient prioritize what's "most necessary" for treatment.  It also makes the dentist attempt to prioritize what would benefit the patient the most knowing that the entire treatment plan won't be done at once.  Although prioritizing isn't necessarily a problem it is almost always a compromise in treatment.
  • Secondly, it reinforces the idea that dentistry is "expensive."  Dental insurance is meant to help with the costs of regular maintenance of dental health.  It's not meant to completely pay for dental treatment.
  • Finally, it adds an unwelcome aspect to the dentist/patient relationship.  Why doesn't my insurance cover more of this treatment?  

Dental treatment is expensive.  But costs can be controlled and planned for when a patient sees the dentist regularly and there is an open and honest communication between the dentist and patient.  The insurance companies often complicate this relationship.

I think one of the problems with this dynamic comes from the confusion between dental insurance and medical insurance.  Medical insurances rarely have a cap on how much will be covered in any given year. If a patient has an expensive diagnosis like cancer, medical insurance generally doesn't limit how much will be paid out for a patient's condition.  However, cancer treatment costs much more than what a company receives in premium payments for an individual patient.  They lose money on that, but society wouldn't stand for an insurance company choosing to limit this payout on a cancer patient.  

A question that's worth asking is "when was the last time that money was discussed with you prior to treatment in a medical situation?"  In most cases the answer is "never."  We don't talk about money when it comes to medicine.  Our insurance covers most of the treatment costs most of the time.  So we accept this "we don't talk about money" stance from our medical establishment. 

Dental insurance defines how much they'll pay in a given year.  The patient makes more decisions about what and how much dental treatment they'll receive, because they're making choices about more of their own money.  

So, as frustrating as it is to the dentist wanting to offer awesome treatment to their patients, dental insurance requires that we talk about money.  At my office, we talk about money before we start treatment so everyone is on the same page.  As much as I wish it weren't the case, money determines dental treatment options as much as anything.  

Why don't we have the same talk about medicine?  Why is health reform such a political hot potato?  I would suggest it's because we don't talk about money with patients.  Patients will make the best choices for themselves when they're given all the information.  I don't pretend to offer solutions to our health care problems, but I do promise to make sure you know how much stuff will cost in my office before we do it.  

Surprises are great at Christmas, not at the dental office!

Questions or comments?  Feel free to email me at:  I read and answer all of my own email and love to hear from readers of the blog! 

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.

Dollar signs.img_assist_custom


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  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.

Does having asthma increase your likelihood of tooth decay?

IStock_000012199167XSmall According to research in the latest issue of the Journal of the American Dental Association the answer is "no."  

This research was a literature review or a "study of studies."  Many of these studies had hypothesized that there was a causative connection between asthma and tooth decay but data didn't support this hypothesis.  

Inhalers used in the treatment of asthma can cause a dry mouth.  Dry mouth is a major risk factor for tooth decay.  To be clear, this research determined that having asthma isn't a risk factor for tooth decay, but using inhaler medications is a risk factor for dry mouth and dry mouth is a risk factor for tooth decay.  If you use inhalers I would recommend chewing sugarless gum after their use to bump up your saliva flow. Along with regular brushing and flossing these precautions should help protect you against any drying that might occur from this medicine.  

Do you have dental topics you'd like me to research and discuss?  I'd be happy to!  Feel free to drop me an email at  I take requests!

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