About Dental insurance and fees-DoctorSpiller.com

Fees, Dental Insurance, and the differing nature of dental practices

The differing nature of dental practices

No two dental practices are alike! Each takes on the characteristics of the practitioner who owns it.  The personality of the owner is probably the  key to how that office “feels” when you walk in the door.  Some practices may feel “clinical and efficient”, while others feel somewhat more home spun and laid back.  The dentist’s personality is reflected in his or her treatment preferences as well.  The fact that different dentists will suggest different plans to treat your condition does not necessarily mean that one plan is better than another.

In my experience, all dentists will suggest what they feel to be the very best plan for any given patient.  The differences between the treatment suggested by one dentist and that of another reflects that dentists preferences based on his or her experience. Thus differing treatment plans do not necessarily reflect any deficiency in either dentist’s judgment.

It is important to remember that there are numerous ways to treat the same situation, and it is always important for the dentist to tailor the treatment plan for each patient’s specific circumstances.  A major part of those circumstances may be financial, and since different treatment plans can vary a great deal in cost, it is helpful if the dentist takes the patient’s ability to pay into account.

Think of treatment plans like various models of cars offered by different dealers.  All of the models are new, have warranties and will work well out of the lot.  The higher end models, however have some advantages not found in the less expensive models.  Some options add years to the life of the car. Some add to the appearance and enjoyment of driving it.  Dental treatment plans are like that too.  Saving a badly damaged tooth with a root canal and a crown will preserve it for a long time, but it is expensive, and the patient may opt for a much less expensive extraction instead.  Replacing a  missing tooth may be done with an expensive implant or fixed bridge(which remains in the mouth and is not removable),  or a much less expensive removable partial denture.  A dentist should be able to explain the advantages and disadvantages of the various options, and allow the patient to make the decision.

All dentists who have graduated from an accredited dental school should be technically competent to perform any procedure that they personally feel  comfortable performing.  But it is important to remember that each one is an individual, and no two dentists can perform exactly the same technical procedure in exactly the same way.  As a matter of fact, no single dentist can perform exactly the same procedure exactly the same way twice in a row!  How well your filling turns out depends as much on how wide you can open your mouth as it does on the technical qualifications and skills of the dentist himself.

Over the years I have developed a respect for those who practice dentistry.  By and large, these are honest people who have the best interest of their patients at heart.  For an interesting perspective on the overall state of ethics in the dental profession, please see my page on bleaching teeth, and especially the section on why it took so long for many of us to accept bleaching as a standard part of dental treatment.

Fees and how they are set

To understand fees in dentistry, it is important first to understand the difference between goods and services. Goods are things like clothing, sinks and automobiles. Services are the human labor involved in their production, installation or alteration. The sink, faucet and pipes are the goods. The plumber provides a service by installing them for you. Goods can be mass produced and distributed all over the world. A service may depend upon the labor and intelligence of a single person.


The price for an item (a good) depends on its availability as much as on its quality. Penny loafers produced by a factory in Taiwan may be sold in two different stores in different parts of the country.  The loafers may be identical, but they are likely to be priced differently depending on the location where you bought them. The same pair of shoes may be much more expensive if you purchase them in an upscale boutique under a fashionable brand name, than if you bought them in K-mart under an off-brand name. In this case, the relative wealth of the local population determines what the price will be. On the other hand, a different brand of penny loafer may be hand sewn and could be expected to be of superior quality, and yet be sold at K-mart for less than the Taiwanese shoes sold at the upscale mall. Again, the price is set by “what the local market will bear”.   Price comparison shopping makes a great deal of sense when shopping for goods.


Services are a very different story, and since everything you get in a dental office is a service (and not a “good”) there is a great deal of confusion in the public mind about its relative value. The value of dental services is not measured in the size of a restoration, or the physical value of the gold, silver or plastic used in its production. The time it takes to perform the service is certainly a factor, and so is the technical excellence of the finished product, but they are not the only factors that count. For example, a dentist may produce a perfectly executed crown to correct your smile, but he may have the personality of a weasel and handle you like a concentration camp guard. How much should you pay to be treated like a human being while receiving the service?   The answer to this question depends upon the patient you ask.  Comparison shopping based on fees will always net you a difference, but not necessarily the one that you expected.

Finally, there is the factor of “overhead”.  It costs a lot of money for a dentist simply to purchase and install the necessary equipment.  The initial outlay is usually borrowed from a bank at interest, and takes many years to recoup.  Most dentists who start a practice from scratch never make a profit during the first two to five years, and must work part time for another dentist just to feed the family.  In addition, the regular monthly expenses are quite large.  Most practices employ several assistants, an office manager, and at least one hygienist.  These people must earn a living wage, and the cost of your filling reflects this fact.

The dentist must pay rent, or mortgage on his office, purchase many types of insurance, periodically upgrade equipment, and provide himself and his staff with continuing education. There are also many incidentals such as lighting, snow plowing, trash removal etc.  One factor that has escalated tremendously over the last few years is the cost of infection control.  Each patient requires several pairs of latex gloves per operator (dentist, hygienists and assistants) as well as expensive disposables such as needles, surgical masks, headrest covers, autoclave bags, and a slew of other things too numerous to mention.  Don’t forget the cost of the expendables such as anesthetic, filling materials, the cost of lab produced items, toothpaste, floss, and much, much more.   The final price of the dental services you purchase must take this overhead into account.

Missed appointments are a major contributor to the office overhead, and they raise the cost of dentistry for everyone.  In our office, we do not double book (book two or more patients for the same time slot).  If a patient does not show up for the appointment, that time goes unfilled.  Nothing is produced to offset the office overhead, and in general, each missed appointment costs that office a considerable amount of money which must be recouped by raising the fees for all procedures.  (We do not over book in our office as a matter of courtesy to our patients.  If two patients are booked for any given time slot, then obviously, someone has to wait a long time to see the dentist.)

Location, location, location

The individual fees for any given service, such as a filling, a cleaning, bite wing x-rays, or a porcelain crown may vary from one dentist’s office to another in any given area. You will find, however, that within a 20 to 30 mile radius from any single office, the AVERAGE of all the fees involved in an entire treatment plan (known as a fee structure) tend to be about the same. You might pay less for a cleaning at one office than at another, but you may pay more for the x-rays. Or the cost of a crownmay be lower in one office than in a neighboring dentist’s office, but you may pay more for the adjunctive services such as post and core or root canals. In general, this is the law of supply and demand in action. A dentist charging much higher overall fees than his local competitors would find his patients gravitating to other offices.

There can, however, be a very LARGE difference in fee structure between dentists in different areas. As a matter of fact, there is a definite gradient in fees as you get closer and closer to a large metropolitan area.  This does not necessarily reflect a major increase in value of the services supplied in those areas (although the rent on the property is generally much higher and adds to the dentist’s overhead). Instead, it is the law of supply and demand. As you draw closer to cities, the population tends to contain a larger percentage of very wealthy citizens, and these people are willing to pay more for services with ambiance. In New York or Los Angeles, you are more likely to find offices with waiting rooms that look like the lobby of the New York Hilton. That atmosphere costs money, and the fees charged for services in those offices reflect the atmosphere. On the other hand, the dentist operating out of his home in East Podunk may be just as capable of delivering the same services as the “big boys” in the city much less expensively.

Dental insurance (and how it works)

What if you have no insurance?

Insurance is a way to maintain health—Not a way to obtain dentistry!
No one should ever avoid needed dental care just because he or she does not have dental insurance!!

Make no mistake. Having dental insurance is good. But it is not essential to gaining access to dental care. On the other hand, medical insurance is virtually essential to gaining access to medical care. In the world of general medicine, treatment for even a minor illness frequently runs into the thousands of dollars. This is NOT the case with dentistry. Dentistry differs from the rest of medicine in that dentists compete with each other on the basis of fees, while physicians do not.  (Consider, for example, just what the cost of a 40 minute surgical procedure would be by a physician compared with that much time and skill in the dentist’s chair.  The difference can be many hundreds of dollars.  And remember that medical services generally bill separately for anesthesia and supplies.)  Most people can afford to pay for dental emergencies out of pocket, and an entire treatment plan can be very affordable especially if it is strung out over the course of a year or two. What this means is that no one should avoid needed dental care just because he or she does not have dental insurance.

Furthermore, if you choose your dentist exclusively on their presence in your employer’s dental insurance handbook, you could be doing yourself a serious disservice. This is because some dental insurance companies use reimbursement schedules which offer the dentist some very perverse incentives, and it could cost you more than going to a dentist who doesn’t accept your insurance. This is explained more completely on my Office Policy Page.


Comparatively speaking, benefits today are FAR BELOW what they were in the 1980s.  This is because, while the cost of living has risen dramatically, benefits have not!  When I started my private practice in 1984, the average “good” plan paid around $750.00-$1,000.00 per patient per year.  Today most plans pay between $1000 and $2000 per year.    It is easy to see that when everything else has increased by about 500% in cost since the early 80’s, $1,000.00 will not go nearly as far now as it did back then.
It is helpful to place the cost of dental care in perspective.  Most patients, even with serious problems, can receive a reasonable treatment plan that will produce (at minimum) oral health and a good smile for well under $5000.  (We are talking about the Volkswagen here, not the Mercedes.)  That assumes a good number of fillings, some extractions and a partial denture.)  This is paid as the work progresses, over the course of the year (or even longer) that it takes to complete the plan.  Paying for this type of service over that length of time can be looked at like making monthly car payments.  If you think about it, it is worth that much to be able to eat and smile without pain or embarrassment.

Something New!—-Bank financing!

Financing an expensive dental treatment plan

Dentists are not banks.  They have no means of checking your credit history, and even if they did, they have no legal status as lenders.  They simply cannot finance your dentistry.  Until recently, patients either had to pay for their dental plans all at once, or do a little at a time until it was all finished.  This often lead to financial hardship, unfinished treatment plans or dental work that never ended.

But things began to change when some financiers figured out that patients are customers too.   When that patient goes into an automobile dealership and purchases a car, he doesn’t have to pay for it all at once out of pocket.  Nor does he make arrangements to drive the car only when he happens to have the cash to pay that month.  He makes a financial agreement with a bank or a finance company to take a loan.  He then gets to pay a fixed amount monthly, the dealer gets his money up front, and the patient/customer gets his new car.

Today we have several finance companies which do the same thing for dentistry that they do for car dealerships.  Now, Care Credit, Wells Fargo, Henry Schein and numerous other large banks will arrange loans that can be used at any medical facility, including physicians, dentists, ophthalmologists, podiatrists and even veterinarians.  You don’t have to make your own arrangements.  The doctor’s  staff can apply for you over the internet.  The finance company checks the patient’s credit and makes an immediate decision about granting the loan.  If the patient is approved, he or she signs an agreement, the money goes immediately to the medical provider, and the patient gets his or her treatment plan from beginning to end with no waiting or dragging out his or her wallet at each visit.  In most instances, the medical provider will even pay the interest on the loan during the first twelve months for the patient.

Some things to know about your insurance

The insurance company will do exactly what is written into its contract with you. No more than that.  The insurance company’s primary allegiance is to its stock holders. It is in business to make money.  Any money paid out for your dental care is money that they do not get to keep!  Any advertising which implies that a big insurance company cares about you personally is only advertising, and is based strictly on their legal obligations to the policy holder. They don’t care if you are in pain, or your mother is sick. They won’t pay for something just because you think you need it. They won’t pay for something just because the doctor thinks it is necessary either.  If you want to know what is covered, read the fine print.

Two employees from different companies may be covered by the same insurance company, but they may have vastly different coverages. The coverage you get is based on the policy your employer buys with the company.  The employer makes the decision about the type of policy based primarily on financial considerations.

The following discussion is only a general guideline to how the basic plans work.  In reality, different plans can overlap so that an HMO may have some of the characteristics of a capitation plan, or private insurance may have some restrictions like those in an HMO or PPO/PDO.  It is very very important to read your policy to find out the specifics about your plan.

Capitation Plans

In a capitation plan, a dentist signs a contract and is paid a small monthly fee for each patient, or each family that has signed up with the plan.  The dentist receives this small monthly fee even if the patient does not show up at the office for treatment.  In return for that fee, the dentist provides exams, cleanings, x-rays and sometimes emergency visits for contracted patients who appear at his door.  In addition, he agrees to a fee schedule for a set number of procedures, some of which may be  paid partly by the patient and partly by the insurance company, or may be paid entirely by the patient himself.    The fees are generally set very low without regard to the dentist’s overhead or local market value. Capitation plans have fared very poorly in dentistry because they frequently do not cover the dentist’s expenses.

Dental HMO’s

Health Maintenance Organizations, were designed to “manage” the delivery of health care.  The HMO acts as a “gatekeeper” and “manages” the expenses by setting the fees and telling the dentist what he will, or what he will not be paid to do.  The dentist signs a contract with the HMO.   He receives a fee schedule set by the HMO and is paid by the HMO for some of the contracted services.  The fees are generally below market value.  If the procedure that the patient needs is not on the list, the patient will have to pay for it out of pocket.  The HMO makes an issue out of telling patients that their doctors are not limited in what they can do for a patient, but the fact that the dentist will not be paid for performing a particular procedure sends a fairly strong message.

The concept of “covered” procedures is not as straight forward as the HMO would like you to think.  A procedure listed on a fee schedule with an amount that can be charged does not necessarily mean that that amount will be paid by the insurance company.  It may be fully paid by the patient.   Thus, the insurance company can state the procedure is covered on the plan, but still pay nothing toward its completion.  This often leads to confusion and frustration, not only for the patient, but for the dentist as well.

Last, most HMO’s require that the patients be treated by a contracted dentist.  This also means that the provider must also refer to contracted specialists.  This is not the case with every HMO, but it is true for most.  If there is no local contracted specialist available, then the HMO may, or may not allow the primary dentist to refer to one that is not contracted.  If the patient sees an out of plan specialist, the HMO is not necessarily obligated to cover any of the specialist’s fees leaving the patient to pay out of pocket.  The other down side to this arrangement is that the insurance company is interfering in the professional preferences of the primary care dentist.  It then becomes possible that the general dentist may be forced to refer to a specialist in which he or she has little confidence.


PPO’s (Preferred Provider Organizations) are like HMO’s in that they have a network of dentists with whom they have a signed contract.  Patients may choose a dentist on the PPO list, or choose a dentist outside the “network”.  Because a PPO dentist accepts a payment fee schedule, the patient’s out of pocket expenses may be higher if he chooses to go to a non PPO dentist.  This is because a PPO fee schedule will generally be lower than the dentist’s current fees, and an out of network dentist is under no obligation to accept the PPO fees.  The difference may be minimal or large.  CAUTION:  It is important to find out if your PPO allows payment to out of network dentists.  Some may not.

Private dental insurance

Private dental insurance is insurance with fewer restrictions. The dentist generally signs no contract with the insurance company. Note that not every employer purchases a standard policy, which is the one described below. Some private policies vary substantially from the standard, and you need to check your company handbook concerning exactly what your policy does cover. In general, dental industry standards traditionally pay under the following schedule:

  • Type I (Cleanings, x-rays, exams, preventive and diagnostic procedures)–100%
  • Type II (Fillings, foot canals, extractions, most surgery)–80%
  • Type III (crowns, bridges, dentures)–59%
  • Veneers, crowns done for esthetics only–0%

Most policies have a yearly limit of $750 to $1500 and a deductible of $25 to $100. “Deductible’ means that the patient pays that amount prior to the insurance paying anything at all.  Please note that insurance plans frequently waive deductibles on Type I procedures.  After insurance payment the balance due is called a co-payment and is paid by the patient.  It is illegal (in Massachusetts where we practice, and in most other states) for a dentist not to collect the co-payment. This may be the case in other states as well.

Within the private insurance sector, there are numerous levels of coverage.  We have computer programs that can give us an idea of your coverage, but we cannot guarantee that the insurance company will, in fact, pay what they appear to promise.  It is important to read your policy carefully.  You can generally find information pertaining to your policy in your company handbook, or in the personnel office where you work.  Insurance companies will NOT usually cover work done for purely esthetic reasons. This includes bonding to close spaces, veneers on front teeth, crowns done for purely aesthetic reasons and bleaching.

Direct Reimbursement

Direct Reimbursement is where the employer directly reimburses the dentist (or the patient) for dental expenses upon receipt of a valid bill.  There is an agreed upon yearly amount that the patient may draw from.  In general, there are no questions asked as to what was done, or why it was done.  That is between the dentist and the patient.  Bill submitted, bill paid – it’s as easy as that!  Anyone having this type of plan does need to check to see if there are any specific requirements (such as time frames for submitting bills) and be sure to follow them.

Direct reimbursement is fairly new in many areas.  It is generally an EXCELLENT type of reimbursement and is a win/win situation for the employer, patient and the dental office.  The employer is saving money by bypassing the costly “insurance” purchase and all the paperwork involved.  The dental office does not have to deal with time consuming insurance paperwork, fighting the insurance company for benefits that weren’t paid but should have been, trying to justify payment for necessary treatment that an insurance consultant won’t approve for payment, or waiting weeks to get approval for a procedure that the patient needs but cannot afford to undertake without insurance coverage.  With direct reimbursement the patient is allowed to apply benefits in whatever manner he/she chooses.  This reduces waiting time for costly procedures and often allows patients more choices in treatment.  For a more thorough explanation of this excellent benefit, both patients and employers who wish to establish a direct reimbursement dental plan may click on this link to the American Dental Association.

Insurance that isn’t INSURANCE

One more plan should be mentioned, because everyone runs into it sooner or later.  They are referral services masquerading as insurance companies.  You might see a brochure in a supermarket or at the mall.  Some advertise heavily on TV.  Generally, the patient pays a monthly fee ($6-$10), and the company refers you to a dentist that accepts their “plan”.

Before signing up for this type of plan, PLEASE call the “plan coordinator” at the company and ask then how much THEY pay toward your dental work.  They generally try to change the subject or give an evasive answer, but if in the end, the answer is “nothing”, then this is NOT insurance.  This is a referral service.  This service will have a contract with a dentist who will accept their schedule of fees. You will find that there are probably only one or two dentists who even accept the fee schedule, and they are located a LONG drive away.
The largest nationwide dental referral service has a 1-800number and advertises heavily on popular TV shows.  Anyone who watches TV has seen their ads.

By calling this referral service, a patient does not receive any benefits, such as low fees or special treatment options from the participating dentists.  Dentists pay a hefty monthly fee for these referrals, and that monthly fee is the only reason they are listed.

A large majority of dentists cannot afford to pay this fee, or believe that this type of advertising is unethical, and are consequently not listed.  Their advertising suggests the the dentists’ credentials are of prime importance to the referral service, but the only reason why any dentist would not be listed is because he or she does not want to pay the monthly fee.  The only service that 1-800-*******  provides is advertising their own business in order to grow a large patient referral list.   Our office has been approached by this service, and we declined.  You may see ads for them on this site.  Feel free to visit their website.  That way they help to pay the hosting expenses for this one.

Insurance that isn’t insurance is starting to crop up in general medicine as well.  You will see advertising on TV that suggests that you can get inexpensive health insurance even if you are unemployed, not a member of a group, or are not eligible for Medicaid or Medicare.  If you see one of these TV ads and happen to have a TIVO or a DVR, back up to the disclaimer box, pause the picture and actually read the small print.  You will be surprised to read that these “insurance companies” do not actually pay the doctor.  The doctor agrees to a discounted fee schedule, but the patient foots the doctor’s bill as well as a monthly fee to the “insurance company”.


Some important questions

What is a Pre-treatment estimate?

A pre treatment estimate is essentially the same as writing to your insurance company to find out what they will cover on a given procedure.  This is a good idea for expensive work.  Unfortunately, the Pre treatment estimate is valid ONLY on the day it is processed.  Therefore, it is only a guideline to payment. (Benefits may have been exhausted prior to performing the pre treated procedure, the policy may have changed, or you may no longer be covered due to leaving your job.)  Even if the pre estimate clearly states that a procedure will be covered, the patient may learn later that the “promised” benefit will not be paid after all.  This is rare, but it does happen.  When it does, the patient is still obligated to pay the entire bill himself.

Is my insurance company good?

This question deserves special attention because it is asked so often.  There are actually two answers to this question.

From the point of view of the dentist and the office personnel, a good insurance company pays what it states it will pay in a timely manner without insisting on unnecessary paperwork.  It has a legal obligation to pay what is written in the contract, but sometimes it can be very hard to collect.  As a dental office, we judge an insurance company by how well it fulfills its obligations to its policy holders, and how much trouble we have to go through to collect that payment.  Unfortunately, this is not usually what the patient is actually asking.

The patient actually wants to know; “Does my insurance plan give me good coverage?”  The answer to this question is that one insurance company may offer hundreds different plans varying from 0% to 100% coverage on any given procedure. Some very good companies offer some very low benefit plans.  That same company may offer much higher coverage plans as well, but the employer decided to purchase a low benefit plan instead.  As a dental office, we are not in a good position to tell you what your particular benefits are. If we give you specific answers, we may be wrong.  To answer this question, check with your company personnel office and compare your plan with the guidelines provided in the standard insurance table above.  Be sure to check the yearly maximum.

Why doesn’t your office accept my HMO (PPO, capitation plan, contract insurance)?

The decision of whether or not to accept a particular plan is based on financial and ethical considerations.  In many instances, the plan’s contract does not provide high enough fees to justify the amount of time the dental office must spend performing the various services.  Sometimes, the restrictions that the contract levies on the dentist may prevent him (or her) from serving what he feels are the patient’s real needs.

Larger offices with numerous associates may be better able to offset the low fee schedule by allowing that office to produce a greater volume of work.  Smaller offices frequently cannot.  By accepting the fee schedule of any of these plans, the dentist is implicitly stating that he agrees with the treatment objectives of the HMO.  The dentist knows the patient, and understands the patient’s needs and desires.  The insurance company does not!  If an insurance company makes ethical demands on the dentist based on their financial and legal interests, the dentist may not feel that he can ethically conform to the treatment plan dictated by the insurance policy.

None of this means that the insurance company is wrong in its policies.  It simply means that each practitioner has legitimate reasons for rejecting the terms set fourth in the contracts offered.

A good example of this type of insurance/dentist interaction comes from the following account of my own experiences with one local HMO.

This particular HMO offered a fairly comprehensive fee schedule.  The patients were “covered” for lots of procedures including extractions, root canals, crowns, bridges, dentures etc.  Unfortunately, the term “coverage” meant almost exclusively that these procedures were mentioned on the fee schedule.  The patient learned, when he got to the office that the insurance company would actually pay only for type I (preventive) work, and fillings.  Everything else on the fee schedule was paid, not by the insurance company, but by the patient out of his own pocket.  If a particularly deep cavity leads to a toothache after the filling, the patient had to foot the bill for the root canal or extraction that followed.

The final straw came when I decided to stop inserting silver fillings in back teeth.  Even though the original contract paid for silver fillings quite well, they refused to pay anything on the newer composite fillings. This happened because composite fillings in back teeth were not included on the original contract, and the insurance company refused to amend the contract.  Rather than treat my HMO patients differently than I treated my private patients, I resigned from that HMO. I lost some patients, but in the end, I didn’t have to deal with patients who were angry with ME because their insurance company refused to pay for necessary dental procedures