Insurance Info | Delmarva Dental Services

Insurance Info

Understanding Dental Insurance

 

Most dental insurance is provided by an employer who contracts with an insurance company. There are two types, Managed Care and Fee for Service (traditional insurance). With Managed Care the insurance company contracts with dentists to discount their fees. Insurance companies have a limited number of dentists to choose from. The practices, willing to participate, lack the patients to keep busy. When this is the case, they welcome discounted-fee-patients. Managed care works well when there is an oversupply of dentists, a number of new dentists starting practices or a large employer in a small town.

 

There are two kinds of Managed Care: a DHMO (Dental Health Maintenance Organization) and a PPO (Preferred Provider Organization). With a DHMO the dentist receives a monthly fee per individual or family. Certain procedures like cleanings and x-rays are at no cost to the patient and others like crowns are discounted. This may sound good in theory but encounters several flaws in reality. Financial reward to the dental practice is greater for under treatment or over treatment. There is little incentive to notify patients for checkups because the dentist makes more money if patients “don’t come in.” There is a tendency to skip preventative procedures in exchange for more costly restorative options. For instance if fillings are free and crowns are not, there is incentive to recommend a crown. The insurance company discourages referrals to specialists and there are a limited number who can be referred to.

 

In a PPO, the “participating” dentists discount their fees by about 20%. This saves the patient, employer and insurance company money in the short term. Take for instance, if the average profit for a procedure in a dental office is 30%, the dentist would have to produce three times as much treatment to make the same amount of money with a 20% fee reduction. Many practices will hire new dentists and pay them less, or charge non-PPO patients an inflated fee to compensate for this 20% loss. The patient with PPO coverage is free to see a “nonparticipating dentist” of their choice. Fee for Service or Traditional dental insurance offers more freedom of choice. The insurance company pays a percentage of the dental fee. Dental insurance is unlike medical insurance in that it only helps pay a portion of care and limits the amount of care. Insurance companies pay a portion by setting a (UCR) usual, customary, and reasonable fee for different procedures. This is an arbitrary amount that varies with different insurance companies and most often is less than the actual fee for a procedure. They also pay only a percentage of the UCR instead of the actual fee. This percentage is usually 50% to 80% or less. The remainder is the patients’ co-pay.

 

Insurance companies limit care in several ways. The yearly allowable maximum payout by an insurance company is usually a $1000 per individual. This yearly maximum has been the same since 1969 when it would pay for 10 crowns but today would only cover about 1 crown. Insurance companies also exclude certain procedures from coverage using pre-existing conditions, missing tooth exclusions, age restrictions for preventive care and the (LEAT) least expensive alternative treatment.

 

Delmarva Dental Services is an out- of- network/ non-participating practice. However, we have over 2700 dental plans in our system that we work with. As a courtesy to our patients we submit claims to the insurance company. The patient will pay the estimated amount that is not covered by their dental insurance plan at the time of the visit. Some insurance companies that we work with will not send us payment directly therefore we collect the full charges at the time of the visit and the patient will be reimbursed by their insurance company.

 

Insurance coverage can be very confusing if not frustrating. Our insurance administrator will strive to help you receive the maximum benefits from your policy and answer any questions you may have. Call us at 410-742-3000.

15 Comments

  1. Just want to know if you except Care Credit?

  2. Doyle except dominion dental

  3. Upper dentures PLEA
    SE help.
    MARIA

  4. Do you work with Delta Dental

  5. Do you take patients without dental insurance?

    • Comment

    • I’m a Medicare & secondary insurance girl. Any hope for me?

  6. Do you take priority partners for someone over 21 and not pregnant???

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    • Comment

  8. Do you take MARYLAND PHYSCIANS CARE

  9. I need your help please. My fiance, high school sweetheart and I have been back together since 25 years ago. I recently relocated to Salisbury 3 weeks ago. After high school Heather, my fiance married the wrong person. He kicked her in the face and she has 3 teeth missing. She is moving down with me on April 15th. We are getting married and having a baby girl in July. I want to suprise her with getting her teeth fixed. I have been saving up everything for this. She won’t smile ever because of the damage he did to her. He died from drugs. I love her dearly. I will call you tomorrow morning. my number is 215-237-5329 Brian Smith

  10. Do you accept delta dental i work at prmc and have not been to a dentist in 7 yrs due to a pamic attack i had in a dentist office where the asistant about drowned me i was tilted back too far. Thats why i have mot been back i need teeth

  11. Can I use credit card Care first to pay for dentures

  12. Do you accept Care Credit for services?

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