From Coverage to Care: Uncovering Insurance Benefits in the Dental Office

Hi, everybody. I'm Dr. Sandhya Moldovan, periodontist and nutritionist. Welcome to the Holistic Dentistry Podcast, the show that gives you the tips and tools to detoxify your mouth for a healthier body. As we explore together the root cause of disease. Remember, you're not healthy until your mouth is healthy. So take care of it in the most natural way.

Welcome, everyone, to today's show on the holistic dentistry. And today I have with me Judy here. And welcome to the show. Thank you, Dr. M. And we're talking about decoding the dental insurance benefits because let's face it, a lot of you have a lot of questions. You don't even know how to bill. A lot of our patients are confused. They're not getting payment. And we just want to clarify, you know, how to do this, how to get the most out of the insurance benefits. And you, Judy, have been in dentistry since you were a baby.

Exactly.

Tell us a little bit about your career in dentistry.

Okay, so my name is Judy. I've been in dentistry. I started out as a dental assistant. So I did chairside assisting, we'll say, 20 plus years. Then after that I evolved and I became a manager. So when you're in a management position, you do a lot of insurance, checking, billing, and trying to get the best benefit for the patient under the guise of whatever the insurance plan is going to allow them to have.

Yeah. So you've been billing now, dental and shaw, you know, for how many?

Over 20 years.

Yeah. So you're, you would say, and you're an expert in the dental insurance field, which is great because I'm not oftentimes, you know, as dentists, we count on you at the front to make sure we get everything we can for our patients in order to help them afford the treatment.

Exactly.

So what are the different types of dental insurances out there?

So a lot of patients today are able to get insurance plans if it's still available through their employer. Some of them have to do it on their own individual. But there's usually three types of dental insurance. You have either an hmo, an epo, which is the new terminology, or ppo.

I heard of HMO and ppo, but honestly, I'm not familiar with the epo. So can you tell us a little bit about hmo? First, let's start with hmo, like HMO dentist.

So an HMO office, and I do have experience there because I worked there for a while. HMO office is a closed panel. So you have to go and see their doctors. They get A certain amount per patient. A lot of the HMO offices will do services, but they'll say upgrades and things like that because they want to try to give the patient the best that they can underneath the HMO environment. But it's definitely a closed piece. If you have an HMO insurance, you cannot go out of the network. There will be no benefits.

So all I know is that HMO pays so little for dental services. It's almost like as a dentist, you have to look at using the cheapest material in order to overcome little amount that this HMO insurance pays. Correct. So that's what you're saying about the upgrades. Dentists are always looking. So, okay, let's say mercury fillings are a covered benefit, by the way, by HMO insurances. And we all know mercury fillings are toxic. So in a dental office, let's say you go, oh, yeah, we can upgrade you to a plastic filling. Let's say.

Correct. So instead. So what the insurance company does in that situation is they'll say, well, you have a benefit for a silver filling, a mercury filling, but the patient says, I want a ceramic filling or a white filling. So they will downgrade the services. So just as an example, say the service was a hundred dollars. And they'll say, okay, you can have a white filling, but we're only going to pay the same amount that we pay on the silver filling. So the patient usually ends up paying the difference.

I see. Okay, so hmo, try to avoid it. Correct. It's not that we have better insurances. Let's talk about EPOs.

Okay, so an EPO is similar to a PPO, but it's a very. It's a smaller panel. A lot of the EPOs are in your medical fields where you don't have such a large amount of providers. PPO is probably the one that you can see a lot more providers, number one. Number two, a PPO will allow you to go out of the network to see somebody that you want an epo. No, you're still locked into a specific provider within that network.

I see. So ppo, let's say somebody has a PPO dental insurance and they're looking, oh, you know, let's see what kind of dentist I can see. What does that mean? A contracted dentist versus out of network.

Okay, so in a ppo, there are a lot of doctors that are providers. The provider, one of the, I'll say the benefit for the patient is if you get work done with the provider, you're only paying a certain amount based on the fee. Schedule that was given to that provider as an out of network provider or someone. If you want to go to out of network, they will still give you the fee, but they're going to base it on again the fee schedule versus the doctor's fees. Some PPO plans, surprisingly, I don't know many that will also do it based on it's called usual and customary rate. Will base it on the doctor's fee. That's few and far between.

Yeah, okay. Yes. I remember when I first started as a periodontist, I used to be contracted with Delta Dental. EPO Dental, Delta Premier. But I remember having problems getting paid and then we had to chase, you know, the money and it was a month later that we would get paid. So I decided as a dentist that I don't want to be contracted anymore with Delta Dental. There was actually a class action lawsuit. I don't know if you remember that in California. I do. Because of the way Delta Dental was dictating the payments. And this is a problem with, you know, dentists that are in network.

Correct, correct. So unfortunately with the PPO plans, even though there's a large network of providers, there is a restriction. They all, Delta years ago used to have a Premier, which was one of their better plans. But when they had the class action suit, everybody went to a PPO fee structure. PPO fee structures are not realistic in today's money environment. It's just not there. They're only going to contribute an amount based on what the plan is.

Yes. And for me, you know, we invest a lot of money in technology and get care of the patient. So, you know, I've decided that, you know, there's. My fees are the way they are because that's what it takes for me to treat the patients at the level that I can best treat them at.

Got it.

And PPOs, oftentimes they weren't offering that rate to even cover my costs.

No, they don't. I don't know where they got the information as to what the fee schedule is, but unfortunately the fee schedule is based on what they're willing to pay and not necessarily looking at what is best for the patient.

Yeah.

Is very limited.

But there's some good news here that even if I'm out of network or those dentists that are out of network, can a patient still get benefits from going to an out of network? If they have PPO insurance?

They can. One of the things that I tell patients who are concerned about the fees is I say to them specifically, ask your plan if it's okay for you to go out of the network? If they can, then we will bill the services, whatever services are there, and they're going to pay according to the plan, but at least the patient will get some benefit for what they have.

Yes, and it does usually. So the check from the insurance, does it go to the dental office or does it go to the patient?

So normally with an out of network provider, we make sure that the patient is reimbursed. Now sometimes they send it to us regardless. So I have to make a call to the insurance company and say, please reimburse the patient. The patient has already paid us. But they should, because we're out of network, they should be providing that reimbursement to the patient.

So you have to do quite a bit of work in the background. And I think a lot of patients don't realize how much work it takes to get paid or to the. For the patient to get paid by, you know, by the insurance. So tell us a little bit of how does a claim get billed?

Okay. So depending on the services are in a lot of offices, they're still doing paper claims. We do electronic claims. So what I try to do when I send out a claim is I try to give them actually more information that they need. So say, for instance, it's a deep cleaning, we'll say it that way. We call it detoxification. You want to make sure that you send X rays to show that there's bone loss. You also want to make sure you send a periodontal charting. You also want to write some information in the remark column. Is there bleeding? Is there inflammation? The dental plan unfortunately, is going to decide whether they're going to pay for it or not. But I feel that I want to do the best I can for the patient and give them as much information as possible to see if they'll pay the claim.

Are photos, you know, of the teeth or gums important or are they useful in order to get paid?

I would send whatever I could just to make sure that they have enough information. And what happens if you don't send it out when you first send out the claim? Now you got the process of let's send it out the second claim, let's send out another one. And unfortunately, with the dental plans, they do not allow you just to add information. They'll say, resubmit the claim. Resubmit the claim. Every time they resubmit the claim, you have to go through the process and it takes time.

Yeah. Can you think of a situation where you had the most Resubmissions on a patient and finally got paid or maybe you didn't get.

Well, some of it, I would say it was probably for some of the specialty services. Now it may be for if doctor was doing recession. That's what photos are great for with recession, because you can actually see. See where the. Where the tissue has receded. But the one thing with insurance companies is it's not. It can't be looked at as only cosmetic. There's a functional problem there as well. So if you address it with functional information, maybe a little help from the doctor that you're doing the billing for, it might help pay the claim, might expedite the claim.

Okay. So once you submit all this information, the period chart, X rays, an explanation of what the problem is, potentially photos, how long does it take for the insurance company to respond?

So if there's information and it can't go through just the regular process where they scan it, it goes through a review process. When it goes through the review process, it could be anywhere from 30 to 45 days to pay the claim.

Okay.

It just depends. Sometimes the review person might say, and usually it's a dentist might say, we need more information sometimes. So again, every time you send something in, it's another 30, maybe 45 days.

Okay.

The cycle.

So it could be as little as 30 days to get a check, or it could be 90. 90 days. Okay.

So it could be a lot more.

Yeah, yeah. So patience is required when dealing with.

Dental insurances, for sure.

Is it easy for you to communicate with dental insurances? Like, if you pick up the phone and call them, are they pretty responsive or you have to stay on hold or.

Yeah, unfortunately, you do have to stay on hold. The one thing I've learned over the years is you have to be very specific with what. What you're asking them because they're just. Most of the. Unfortunately, the customer service people are just reading information off of a screen. So what I find helpful is that if the insurance company will allow you to put certain codes in there, asking for the codes and not so much just asking for, you know, the services, you might get a answer quicker.

Oh, okay. Now I want to talk a little bit about pre authorizations. Okay. Because we have some patients that are actually asking you for this.

Right, right.

So what are pre authorizations and are they guaranteed to pay?

Okay, so pre authorization really is saying to the insurance company, can I do this treatment?

Okay.

Okay. That's really what you're asking? I've done it in the past before. And the reason I've done it. Is because people feel that if they have a dental plan, they want to see if it's going to help them out. Okay.

Yes.

Once you get the pre authorization back, it'll tell you information what the fee was you're charging, what the fee is they're going to accept, what percentage they're going to pay on that fee. It'll say there's a plan benefit, but right at the very top of it it says this is not a guarantee of payment. And the reason they do that, and I've had this happen to me in the past, is people think, oh, I have insurance. Let me just get pre authorization and I'll do the work later. Well, the pre authorization is not paid until they check again for eligibility. If you are not eligible at the time of the service, the pre authorization is no good.

Oh, okay. So a pre authorization, once it's received, is good for how long?

I believe it's 30 days. Sometimes it goes up to six months. It just depends on what the procedure is.

Yeah. Okay. So is it worth doing these pre authorizations if.

Yes and no, Most of the time it's not going to give you enough information. And the other thing it does, it postpones the treatment for the patient.

I see.

So I would say to the patient, you have something. We'll do the very best that we can to maximize the information. As you know, it can't guarantee it, but we don't want the insurance company to hold up something that's going to help your health.

Makes sense. And I always say that as well, you know, insurance companies do not dictate the kind of treatment we recommend for you, nor should you go by. Well, I'm just going to do what my insurance recommends. And I do hear that insurance companies are not medical or dental providers.

Correct.

And they don't know what's in your best interest.

Correct.

Now, there's also a yearly maximum with dental insurances and deductibles. But let's talk about the yearly maximums.

Okay. So most dental plans, years ago, the maximum was $750. I think it's gone up a little bit to 1000. I've seen some 1500-2000. But what that means is there is. We'll just say as a pool of money. There's an amount of money that has been set aside for you for the year to use. Now, maximums do not guarantee that you're going to use all of the maximum because there's other criterias that are involved with it as well. But so think of it as a pool of money that's put aside for the year for dental services.

Okay, so in that thousand dollars, does it include both preventatives such as cleaning and exams and treatment, or this is $1,000 just for treatment.

Anything. Anything that's needed, whether it's preventative, restorative, something that's more extensive. Yes.

Yeah. So in terms of preventative care, how often do insurance companies actually cover the dental cleanings?

They will cover the cleanings based on a percentage. Again, it's based on a fee schedule. And they will tell you it's a percentage of the fee schedule. Normally it's about 80%. But keep in mind these days, where they used to do 80% on the cleaning, right away they're adding deductibles and things like that, which they didn't do before.

So what's a deductible? Like $25 or each plan is different.

Some are 20, 25, 50. It's applied to the service that they feel either the first service of the year. And that's why I bring up with the cleanings, because they might. It's $25 deductible. So what that means is. Let's give you an example. Let's just use a dollar amount. It's $100. Okay. They're saying, okay, you have a deductible of 25. So they take the $25 away from the hundred. So now it's $75. Okay. They're going to pay based on $75. If their fee is 50, then they're only going to pay $25.

I see. Okay. So I'm glad we're talking about this because a lot of little details are coming up here. I want to ask you about holistic dental services because we do have some overlap there. And I want to talk about what does a dental insurance cover in terms dentistry? So let's talk about. Since we were talking about prevention and cleanings, we do airflow guided biofilm therapy. Here is our dental cleanings. Is that a covered service under the dental cleaning?

Well, under. Underneath the dental plan. All dental dental plans work with what they call ADA codes, which is the American Dental association code. The airflow that we use is the technology that we feel is best for our patients. There's only one code for prophyl, for profi.

It's 1110, meaning removing biofilm.

That's it exactly. So they're going to pay based on what the plan dictates.

Okay.

Yeah.

What about like ozone water irrigation? Would that fall Under a certain code in the ADA that's billable.

They do have a code that's billable for what they call irrigation. So I've tried different ways just to see what will help the patient. I do it one area at a time. I do half the mouth. Because under their guidance or under their understanding, they're using a material or an irrigation that we don't particularly like. We like to use ozone. So I try, but I don't see a lot payment on the irrigation. I will bill anything until they tell me no. I will make sure I have the information that goes out with it. And then again, it's up to the plan whether they're going to pay for it or not.

By the way, ozone irrigation is used a lot when you have gum inflammation in the office. And we recommend it in order to make sure we flush out the inflammation and set you on the way to health. What about lasers? There's a lot of dentists right now, and lasers have been around for 30 years. It's not new technology. So let's say laser bacterial reduction, it's actually FDA approved. Is that a covered benefit?

That part is not. But the way that the dental plans look at anything that's used with laser, the modality, say for instance, doctor, is flapping something. It doesn't matter what modality you're using, whether it's laser or you're using a scalpel, the code is the same. They don't care what. What it is. Some of these other things. Unfortunately, the codes that we have to use for laser are not ADA codes, so they do not cover it. But any, any modality that use a laser with that has a code, then yes, they will pay something on it. Based on a plan. Again, everything's based on a plan.

So for cavitations, let's say cavitations being a procedure where we remove, you know, infected material from the jawbone and actually send it for biopsy. Is there part of that cavitation that's potentially covered by dental insurance?

Some of it is. We've had a patient that I've sent it on. Surprise. They did pay something on the whole procedure. Based on which part of the procedure? I can't tell you, but I was just happy the fact that they should.

Yeah, right. And then also in holistic dentistry, we have biomimetics. So. Meaning we're using ceramic dental fillings, which is basically is not the modality. As you were saying, they'll cover whatever it is that they're going to cover filling.

Correct?

Correct. Or what about inlays and onlays.

One of the things that you want to make sure of when someone is doing your billing for you is you want to make sure there's a reason for doing certain things. Medical necessity is the key word. It's used in medicine. It should be used in dentistry as well. Dental plans will always look for the least expensive procedure, so documentation is critical. Why do you want to do this? Is it better for the patient's tooth? Is it going to work better than, say, having a filling done? Because with filling, sometimes the dental plan, if it's happened more than a couple times in two years, they won't pay for it.

I see. Okay. So, for example, if somebody is like getting a removable partial denture, right? They have some missing teeth to replace, let's say two teeth on the upper right. And later on, let's say a year later, they decide to do a bridge. Is that bridge gonna get covered or is it. No, because they've already had something removable.

Depending on how it was billed, if you sent in the dent to the dental plan that you had a temporary there and they paid on it, then they won't apply anything to the bridge. Okay. Most patients will pay it out of pocket and save the benefit that they have for the bridge and do it that way.

That makes sense. Alternative benefits. This is a term that actually you taught me. I knew nothing about it. And I think there's a lot of patients out there or dentists that know nothing about this. So let's dive into alternative benefits. And what does that mean?

Okay, so. So what happens with an alternative benefit? And I learned this a long time ago. Say, for instance, the patient has a couple of missing teeth and they want to either replace it with a bridge or implants. And of course, the dental plans will say, was it taken out at the time you had the plan? If not, has it been out a long, long time? Okay, we won't cover it. So what I do with the dental plans is I'll say to them, would you give the patient an alternative benefit? Which means, would you pay for a removable partial? Let's take that benefit money and apply it to either the bridge or the implants. But you have to ask for it. If you don't ask for it, the dental plan is not going to offer it.

Wow. So what about the people listening to this conversation? They're thinking, oh, my God, you know, my dental office doesn't build dental insurance. Can a patient actually call the dental insurance and ask these questions?

If you. If you get the help from the dental office with the codes that are going to be used. Yes, they will tell you. The one problem with that is they can't tell you how much. They'll give you a percentage because they have to know whether the doctor's in network or not. Okay, so that holds it. But they will tell you if there's a benefit for the procedure. Yeah. Okay.

Percentage wise and in your opinion, what is the best dental insurance out there that you want? Oh my God.

Wow.

This is the best. You're going to get the most amount of money. Is there such a thing?

Good question, doctor. None. I'll tell you flat out, none. So what I tell patients is I tell them now they have to make their own decision. I tell them, why don't you add up what you're paying for a premium. Out of that premium, how much are they paying for you for the year? Because people think, oh, I have $1,000. Everything is based on a percentage. Trust me, if you don't have a lot of work done, you're not going to use the thousand dollars. That's just the way it goes. That's how it operates. They keep their money, they don't want to give it to you.

Yes, makes sense because after all, dental insurance is a business. Exactly. When it comes to dental plans or memberships, memberships are a newer thing for dental office. And there's a couple different companies actually that are offering these services for in house benefits. So what does that mean to have a membership within a dental office and how is that beneficial for a patient?

So if some offices have it, they might have a plan put together to you pay so much per year and it gives you so much. We happen to have one in our office which I think does a lot more for the patient than their dental plans. So what I say to the patient, I'll say, this is our membership plan. It covers your routine maintenance per year. So in other words, it could be three or four cleanings. In our office, it's an airflow in ozone, which is a great combination. It covers your yearly visit with your general dentist, unlimited X rays, a CT scan. At one point it could be a half off, or it could be at no charge. The other nice thing as a perk with these plans is if you have your maintenance taken care of for the year. And what if something comes up? You need a crown, you need a filling or something like that. One of the membership plans reduces it by 5%. Another one reduces it by 10%, which is great. Nobody offers that these days. On services. The other good thing about it, I say to the patient, look at what we're charging for our plan. Are you paying more than that for a pre. If they are, then you're losing. Because in our plans there's no deductible, there's no limits and we make sure you're taking care for the year. The other thing with the, with our program, our membership and maybe other offices, I'm not sure, is that we offer either three to four cleanings a year. You will never find that in a dental plan. It's two. They figure everything is six months, which we believe is not in the best interest of the patient.

Absolutely. And actually as a periodontist, I got to look at studies in my residency and we know at the three month mark bacteria that is left at the gingival level goes subgingivally and it can actually turn more pathogenic. So that's the reason really that we like cleanings every three months and the insurances with twice a year, they're just basically dictating that based on their, you know, their income.

Exactly.

You know, and making it profitable for them. But there's scientific evidence why getting a cleaning every three months is.

It is most of the time when patients come in, I can just tell you as our patients that come in their mouth feels a lot, a lot better when they come in every three months. And we can maintain them better and keep them healthier.

Yes, yes. Because the mouth is a gateway to health.

You got it.

Now, you know, as last time, just a remark. If there's one thing that people out there with dental insurances should know, or like a pearl that you can give them today, what would that be?

Let me think. That's a hard one. I would say first of all, if you have a dental plan that is being paid by the employer or it's a minimum amount, use it, use it as much as you can. Don't let it dictate to you the treatment that is going to keep you healthy. That's the first thing I would say. It's a benefit. It's not telling, it's not your subscription to what you need for the year. It's a benefit. So take advantage of the benefit for what it will pay for you. But keep in mind what's good for you is good for you.

Okay, that's great advice. And with that I thank you very much. Really giving us a lot of great information about dental insurance. Everyone, we'll see you next time.

Thank you so much for joining me this week. Please make sure you check out the show notes for any links mentioned in the show. If you like today's show, please invite your friends to listen as well. That would mean a lot to me. Do you have a question you'd like me to answer? Message me on Instagram. Rsanda, this is Dr. Sanda. And remember, your mouth is the gateway to your health. So take care of it in the most natural and best way possible.