Is Your Dental Insurance Company Ripping You Off?
Dental Insurance coverage is a highly prized abenefit, and with good reason. Excellent dentistry can be costly and insurance can help reduce the out-of-pocket cost the the care you and your family need. Frequently, however, the benefits you receive don’t match up with what the insurance company promised you when you signed up. Your plan mya pay a smaller portion of the cost than you think they should, shifting a larger portion onto you.
What you need to realize is that your insurance comapny’s top priority is not helping you get the care that you need, it is MAKING MONEY. And the less care you get, the more money they make. Many people already noticed this same infuriating trend with medical and prescription insurance, where plan limitations and sky high deductibles have left them responsible for more of the costs.
The following deceptive dental insurance practices are not new, but they have become more prevalent in the past few years. These companies have spent years stacking the deck in their favor. Here are a few of the ways they keep more of their money.
- Artificially low annual maximums
Does your plan still carry an annual maximum of $1500, $2000 or even just $1000 per year? If so, you’re being ripped off. Back in the 1970s, dental plans average annual maximums were $1000-$1500 . That was the most they would pay towards your care in any one calendar year. And here we are in 2025 with the same annual maximums!
2. The UCR, “usual and customary” fee scam
Your dental plan has specific dollar amount that they will reimburse for each procedure. They call this list the “usual and customary” fee schedule, implying that it is based on average or typical fees charged by dentists in your area. It isn’t. They won’t tell you how exactly they determine these fees, probably because they always set them lower than average for fees in your area. When you are required to pay the difference it is again your insurancej company ripping you off. Not the dentist. The insurance company.
Fortunately, there is objective, unbiased data available for consuners to compare and see what the average real usual and customary fees are in your area. If you go to www.fairhealthconsumer.org you can search any dental or medical procedure by zip code. If you compare these against what your insurance company is paying, you will see how little covereage they are actually providing you.
3. Frequency limitations
Human beings are individuals. YOU are an individual. Your dental needs aren’t the same as everyone else’s, but dental insurance companies fit your needs into the same convenient, profitable boxes as everyone else. If you had kidney disesase and needed dialysis twice a week, but your insurance only pays for treatment once a week? Outrageous, you say?
Yet, dental benefit companies do this all the time. Whether you need treatment for periodontal disease, tooth decay, TMJ or any numberj of other conditions, your benefits can be hindered by an arbitrarily selected frequency limitiation. Patients with gum disease may need cleanings 3 or 4 times a year. But if your plan limit is 2 per year (a common but completely arbitrary number) your specific needs are irrelevant to them. They’ll require the additional visits to come directly our of your pocket. The insurers are again shifting the cost burden onto you will maximizing their profits. Sounds like a rip-off to me.
4.“Preferred Provider” network
Some dental plans have networks of “preferred providers” and encourage you to see only dentists on that list. You might assume that dentists get on the “preferred” list because of a higher standard of quality, experience or professional excellence. This just isn’t true. In fact, insurance companies check only that the doctor is lisenced and has malpractice insurance. That’s it. That’s their standard. Doctors get on their “preferred” list only one way: by agreeing jto accept lower fees than normal. Much lower actually. Can dentist participate in these networks and still provide good care? Yess, they can, but with greater and greater difficulty. And it certainly doesn’t help the dentist by the insurance company bureaucrats looking over the doctor’s shoulder and second guessing or flat out denying the care your dentist is advising.
The real question is: Does your plan reimburse you ONLY if you visit in-network doctors? With some plans that is the case, and will not reimburse you anything should you choose to go out of netowrk (but they sure will collect your premium!). But with the vast majority of PPO plans you are free to go to ANY doctor, in or out of network. They encourage you to go in-network because it saves them money. If that isn’t a rip-off, I don’t know what is.
Off course, many of these decisions are made not only by the insurance company but also by your employer when they are designing your dental plan options. Your employer may not even be aware of some of this disturbing tricks insurers use to restrict your care options. You can speak with your HR and even forward them this list.
At your next open enrollment, don’t just check the box next to the cheapest option, because that may end up becoming a much more expensive decision. The cheapest up front may cost you more down the road.
You also need to look over those forms the insurance company sends you in the mail. When they refuse to pay for somehjting, theu’re required to give a reason as well as the opportunity for you to appeal the decision. if your dental benefit company refuses to cover some necessary treament, you should speak to your dentist as soon as possible. The insurer is hoping that you will just accept their decision and not complain. It is always worth trying to appeal. It is not always successful, but if you don’t try, its definitely not covered. We hate to see our patients ripped off and will try to help you as long as you reach out to us.
reprinted from an article bu Mitchell Rubinstein, DMD