man sitting at a desk using a calculator

Many patients think they have great dental insurance and are disappointed when the reimbursement is lower than expected. Patients can have unrealistic expectations about their reimbursement because many insurance policies are confusing.

My practice team has focused on the following key points to explain the realities of dental insurance to patients and it has worked well in our practice for many years:

1. Annual maximum benefit

Your dental plan has an annual maximum benefit, which is the most your insurance company will reimburse you each year. The annual maximum benefit usually ranges from $500 to $2,500 and is determined by your employer and the insurance company.

2. Reimbursement of different services at different rates

Your dental plan will reimburse different procedures at different rates. Your insurance company usually divides dental procedures into three broad categories. The first category is preventive procedures, which usually includes diagnostic procedures and simple dental cleanings. The second category is basic procedures, which usually includes fillings and root canals. The third category is major procedures, which includes crowns, bridges and dentures.


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3. Usual and customary fees

Your dental plan will create usual and customary fees for each procedure. These fees have no relation to the actual cost of your dental treatment and are artificial numbers generated by the insurance company to limit your reimbursement.

While your insurance company will claim to reimburse you 100% for preventive procedures, your reimbursement is lowered through the usual and customary fee clause, and may be closer to 75%. Your insurance company will claim to reimburse you 80% for basic procedures, but the real number may be closer to 50%. The insurance company will claim to reimburse you 50% for major procedures, while the real number may be closer to 25%.

4. Insurance doesn’t reimburse for every procedure

Your dental insurance will not reimburse you for many procedures that you may require. Most insurances do not reimburse, or reimburse at a low level, for implant dentistry, esthetic dentistry, adult orthodontics and temporomandibular joint/bite problems.

5. The best uses for dental insurance

Your dental insurance is useful for cleanings, minor fillings and fixing about one tooth per year. While this may be fine for some people, others may require a more comprehensive approach to treatment. We will work together during your initial appointments to determine what approach is best for you.

6. The difference between dental and medical fees

Dental fees are set differently than medical fees. Most medical fees are not accurate reflections of the costs incurred for medical care. Most medical fees appear higher than normal since the insurance companies will lower the fee when paying the claim.

Since many patients do not have dental insurance, fees are set differently. Dental fees reflect an accurate accounting of expenses incurred for treatment. Therefore, it is not possible to charge different fees for patients with or without insurance.

Explaining the realities of dental insurance will result in a more transparent discussion between the patient and the dentist. We typically have this conversation early, during a new patient initial interview, in order to address any insurance concerns.

When we have this discussion early, patients are more open to hear about both insurance and non-insurance based diagnostic tests and treatment options.

Jim McKee, D.D.S., is a member of Spear Resident Faculty.