Transcript
Episode 4: Dental Insurance Is NOT Insurance and What To Do Instead
This is Dentistry Disrupted with Dr. Craig D. Clayton. I'm a wellness and biomimetic dentist, passionate change maker, social media thought leader, and educator on disrupting the way we approach oral health care. Come along with me as we journey towards a healthier and more empowered you.
Hello, hello, welcome to this podcast episode. You guys are loving the reel about insurance with me, uh, escaping through the sealing hatch in my mechanical room. Okay. So we are going to dive into dental insurance and debunk a couple things and explain it properly. So I, we just, we couldn't wait another moment to get this out here.
So bear with me. We, my family's going, uh, pretty sick right now. We are all getting taken out by the flu one by one. Eli's the sickest right now. Our boys are finally getting a little better. I'm so so hanging in there. So that being said, we are not going to do a lot of edits to this. So in advance, please forgive any stumbling, any rough cuts.
I'm just gonna do our best to get this to you as soon as possible. Diving right in. Dental insurance. Here we go. I'm going to rant initially for a little bit, give you some good comparisons, some good ideas. Uh, to be able to understand the difference between dental and medical insurance. I feel like this is paramount to be able to understand, uh, why dental insurance is not working in your favor.
But at the end, we're going to give you some actionable items. So we'll go through five different options that are alternatives. To dental insurance that will help you get the care that you need. Hang in there. I am not going to leave you high and dry. You'll walk away knowing some options, okay? Let's dive right in.
First, we're going to talk about dental insurance versus medical insurance. We'll start with medical insurance. So the reason why we have insurance in the first place, right, is risk mitigation. To be able to protect ourselves if something catastrophic happens. So the point of medical insurance is you pay into a plan each month and then in return they cover costs for medical care.
Usually you have to pay, you know, on average for the US you have to pay about 2, 000 out of pocket before insurance starts to pay a little bit. And then sometimes that's quite a bit more, but there's a cap at how much you'd have to pay. So here in the US Per person, once you have paid, on average, 9, 450 as an individual, that's when your insurance kicks in and covers everything else.
As a family, uh, it's about up to 18, 900. And these are numbers that are set by the U. S. government to keep things fair. And once you pay up to that 18, 900 as a family, then after that, um, everything is covered, all of it. It's really amazing. It's a huge blessing. It's super expensive, uh, but when something catastrophic happens, it is well worth it.
So let's give an example. Say you go to a well check. The doctor finds a, uh, a lump in the throat. Uh, you go and get it checked out, it gets biopsy, biopsied, and it ends up being cancer. Now you are saddled with the costs of surgery, chemotherapy, a lot of treatment. Well this could, this could go into the hundreds of thousands of dollars.
But with medical insurance, again, you're, you pay either that 94. 50 or that 18, 900. And once you hit that number, everything else in that year is covered, everything. So really beneficial. You have to keep in mind though, that this is for in network providers that you go to. With insurance, they're picky. So if you have an insurance plan and you go to an out of network provider, that maximum is 19, 900.
is not guaranteed, uh, by the law the same way it is if you go to an in network provider. So, keep that in mind, and I want to let you know we will have some show notes with a couple of the resources that I have consulted to put these facts together. I have also consulted with a professional insurance agent.
And have run by these calculations and have run these calculations by him as well as the explanations to make sure that I'm accurate. And the only thing that he added was make sure people know that this is applied to in network, uh, this is for in network providers. Okay, I hope you understand that. So insurance, medical insurance to recap, you pay a monthly fee.
And that can be, you know, 2, 000 per month for a family, 1, It can vary. On top of that premium, you have to pay out of pocket until you reach what's called um, a deductible. So deductible is The amount set by the insurance, the minimum amount you have to pay out of pocket before they start paying any cost, any percentage of cost.
So, add your premium monthly, your deductible on top of that, uh, that's what you're paying out of pocket. And again, once you pay those maximum amounts in, in the year, Um, then everything else is covered to take care of you. So, so I have to re emphasize. This is really important. Medical insurance is to cover catastrophic events as well as help out, um, with, with less severe events if you have a lot of medical bills, uh, one year or another.
Risk mitigation, that's what it's all about. Okay, we're really getting into the weeds here. I hope you're following. You have to understand this really well to understand dental insurance. Okay, dental insurance is the opposite of medical insurance. And let me explain why. Remember how medical insurance you pay a monthly fee, and then you pay a minimum before that medical insurance kicks in, and then after that, when you hit a certain amount, insurance covers everything?
Okay, dental insurance is different because, yes, you pay a monthly fee to your insurance, and yes, you pay a minimum. It saves a couple hundred dollars, uh, or more until you hit that point that insurance kicks in and starts paying. However, you have a maximum. So with dental insurance, it's on average dental insurance in the U.
S. is the maximum is about 1, 500. That means you're going to pay monthly, you're going to pay out of pocket, and once you meet certain criteria, then insurance kicks in and pays, but they'll only pay 1, 500. Okay, let's pitch some examples here of why this is not insurance, because it's not covering risk. Say you haven't been to the dentist in a while.
You have a lot of anxiety around dental treatment. You have a bad history of, maybe traumatic experiences. You've struggled with getting cavities. So you, you gather up the courage, you go into the dental office, and as you feared, you have a lot of treatment that needs to be done. New cavities, fillings that are failing.
Crown's that have failed. Maybe there's an infected tooth that needs to come out and be replaced. All these things are important. And you absolutely don't want to just do one tooth at a time. Because what happens if you treat one tooth at a time instead of taking care of the entire oral environment?
You're going to constantly be chasing your tail. You're not going to fix the problem because you're just fixing one little, uh, uh, symptom of a much greater problem. Okay? So, you've gone in, you get this verdict, you get the treatment plan, and say it's 12, 000. You need an implant, you need new crowns, um, you need onlays, you need to replace fillings.
It's 12, 000. Okay? If this were medical insurance, they would cover up to a certain point and they'd say, okay, um, or you, you'd cover up to a certain point. And then, uh, insurance would click and say, okay, we got, we got the rest. We got you, we got your back. We're going to take care of you. Dental insurance says, okay, you pay us all this money and then we'll pay you.
We'll pay maximum of 1, 500 over the year. Maximum. But you have to take into account you have been paying monthly to this insurance plan. You have been paying out of pocket for your percentage of treatments. You have paid your deductible, so say you've paid in 900 bucks or 600 bucks. Whatever it is. You have to deduct that from your coverage.
So in reality, yeah, you have 1, 500 of coverage, but you've already paid 800. What are you left with? You're left with 700 to go towards that treatment. Doesn't get you very far. And this is why I'm so frustrated with insurance. Because one, it's, it's the wrong term. Dental insurance is not insurance, it's a discount.
It's a discount of a couple hundred dollars or, best case scenario, a thousand, fifteen hundred dollars and that's it. They don't have your best interest in mind. They're not actually protecting you from risk. They're just paying as little as possible and collecting as much as possible and hope that you don't go to the dentist regularly or that you only need, you know, one thing or another.
This is how dental insurance works. And I can't emphasize this enough, I just, I can't emphasize this enough that medical insurance covers your risk. They have your back when things get bad. Dental insurance gives you a discount. They pay a lump sum towards your treatment. You get in a car wreck, you need, um, a full mouth reconstruction.
You need a, you know, uh, you fall, have an accident. You have a 50, 000 treatment plan to be able. To replace all your teeth, get you back to normal function, get you healthy. Great. You get 1500 bucks for that. It's not going to do much when the treatment plan is 50, 000, uh, because of the severity of the problem that needs to be fixed, let's talk about another issue with dental insurance and, and hang in there, I am going to get to the alternatives that you can use to get the coverage that you need.
Insurance is. One of the driving factors, in my opinion, in the opinion of a lot of other doctors, of this cycle that we are stuck in, of chasing our tails and doing reactionary dentistry is what I call it. You get a cavity, you get a filling. You get a cavity, you get a filling. You get a larger cavity, you get a crown.
Maybe you get a root canal treatment. Maybe you extract a tooth and get an implant. Maybe you have to get multiple teeth extracted. Insurance will pay for those things and you'll pay for those things. But we're not fixing the problem. And why? Insurance doesn't incentivize preventative care. If insurance worked in a preventative way for dentistry, then they would be reimbursing doctors and incentivizing them.
to do more education, to teach about caries disease, to teach about cavity prevention, to teach about less invasive options, to teach about gum disease, what to do about it, pay for saliva testing so we can actually fix what's going on with the tissue in the mouth, the gum tissue that's irritated, bleeding, causing bone loss.
They would incentivize doctors to actually focus on the root cause driving these conditions in the mouth. rather than just paying 1, 500 for reactionary treatment. In my opinion, again, this is one of the things that is causing dentistry to be broken as an industry. And on top of that, insurance, you know the rate of reimbursement for insurance or the maximum out of pocket that they pay, the 1, 500 on average?
That has not changed in over 50 years. Do you think costs have gone up since then? Absolutely. Medical costs, dental costs, cost of living, um, cost of housing, everything is significantly higher than it was in the 60s. Yet, that maximum has stayed the same. Not only that, but dental insurance is doing everything they can to pay providers less.
Here's a fact. I have a friend in Arizona. And I was speaking to him, and he just decided to go fee for service, meaning that he's not contracted or in network with any insurance company. And the final straw for him is when he and every other dentist in Arizona got a letter from one of the biggest insurance companies in Arizona saying that they would now be reimbursing less per procedure.
What? This doesn't make any sense. Nothing. Inflation's high, interest is high, cost of living is so much higher just in these last couple of years and they're paying the dentist less? That is why the dental industry looks how it does. I do not, for a second, blame the dentist. Sure, there are always outliers.
Always, there are always those rogue people that don't fall into this category, but I believe that the vast majority, 99%, 99. 5 percent of dentists are doing the best they know how and they're stuck in this loop because they're chasing these patient, these insurance reimbursements for the treatment that are becoming less and less.
So what does that result in? You have to do more and more dentistry in less and less time. That is the major focus for so much continuing education these days. How can we do more in less time? How can we be become more efficient? And do more in less time because we need to get paid more because we're paying 60, 70 percent overhead just to keep our doors open and insurance is paying us less.
So do you think these doctors want to sit down and spend a half an hour, 40 minutes with a patient talking about Cary's disease? And how to stop the disease so you stop getting cavities and stop getting fillings and crowns and losing teeth throughout your life? Sure, they'd love to, but they can't. They can't.
Because they're not going to get reimbursed for that. And if they get reimbursed for that, it's going to be very little. And they can't operate a practice off of speaking and educating patients. They have to do procedures. Therefore, it doesn't incentivize them to go out and learn more conservative treatment, to learn more preventative treatment.
We get stuck in this cycle of Dennis of doing things the way we've been taught for decades. Never mind that in, that dental schools take a long time to implement modern science. Never mind that there are better resources out there. We don't know as Dennis, because we're so buried. in trying to make a living and pay off our debts.
So gone are those days of coming out of school, having low debt, being able to make a very good income from dentistry. Students, on average, are graduating with somewhere between 325, 000 and 400, 000 of debt. I graduated with 464, 000 of debt, with a 7 percent interest rate across these loans. I had to spend another 600, 000 to open up my practice.
The cost of treating patients is enormous. As a result, I am a fee for service office. Because I can't spend an hour and a half with patients and get reimbursed a hundred bucks like I was when I worked in insurance practices. Where I spent ten minutes with a new patient, I got reimbursed, uh, I got paid a hundred dollars for that ten minutes.
Uh, now I spend an hour and a half, like, I can't function off of a hundred dollars. But, what I'm passionate about is fixing the problem. Fixing the problem. And I hope that this is making sense to you. That you're starting to ease up more on, and so many people get hung up on this insurance thing of my insurance doesn't cover it.
My insurance doesn't cover that provider. I want to go to that person, but my insurance doesn't cover it. Your insurance doesn't cover 900. Is that worth getting lesser treatment? Is that worth getting a lesser experience? If it is, Then, by all means, you can pursue that and there are plenty of offices stuck in this vicious cycle.
And I'm so sad for them and the doctors that they have not, they don't know how to do this. There are plenty of people you can go to that will take your insurance and maximize every single benefit and you'll pay the least amount possible. However, if you're seeking preventative care, if you're seeking biomedic dentistry, if you're seeking education, if you're seeking preventative oral health, comprehensive wellness, it's going to be very hard to find this in an insurance driven practice.
That's why I recommend people really think hard about this decision. Really think hard about it. Because here are some things we can do instead of dental insurance. We can open an HSA or FSA account. So you put money in those accounts. Pre tax, and that money that's kept in that account and used for health care is not taxed.
So it's a great way to lower your taxable income so you pay less taxes, but then you're also, you're also able to pay for your health care and save up over time. So, great things. Talk with your bank, do some googling, uh, and I know you can find options to do an HSA or FSA. Another thing, in office memberships are becoming increasingly popular because it is so much better for a dental practice to offer an in office membership.
Kind of like an insurance where you pay a lump sum and it covers X amount of procedures and discounts. You know, such procedures. For example, you pay, you pay 600 and it's going to cover all your preventative care, your cleanings, x rays, whatever. And then, on top of that, they say, okay, well, because you paid into this plan, we're going to give you 30 percent discount on fillings and crowns and whatnot.
So, if you have a big treatment plan, You very well could be saving the amount of money you'd pay into insurance, or more, but you're not having to deal with the frustration of insurance, especially when the provider you want to go to is out of network. In office financing. Some offices offer some financing, splitting up payments over three months.
This is very Case by case, uh, because this does put, you have to understand this puts the provider at risk if they have someone, uh, that needs 4, 000 of treatment and they say, I want to split it up over three months and then they run away and cancel their credit card. That is, uh, that's a liability. So it is case by case.
So you have to talk with this, this, the office that you want to go to, to figure out if that is actually an option. What I think is one of the best options is third party financing. And a lot of people say, Whoa, Whoa, Whoa. I don't want to open another credit card. I can't do that. That's going to hurt my credit.
Why do I want to, why is that a good option? Well, here's the reality. When we open credit accounts. and pay off our credit, we increase our credit score. We are financially, a pair financially more responsible to these credit bureaus, which then impacts us positively later in life when you want financing for a house, when you want financing for a car.
But the best thing about this is that you have a lot of time to be able to pay this off. For example, Alfion. is one that we use, and we also use Care Credit, but I think Alfion, in my opinion, is the best. Say you need to come in and you have that 8, 000 treatment plan. You can get all that treatment done.
And as you go, that treatment is charged to your Altheon account. From the moment that, that payment is run and charged, you have 12 months to pay it off interest free. If you don't, if you pay it off in 12 months and one day, you're going to be hit with a huge amount of interest, 19, 20 something percent.
However, if you paid off in that 12 months. It's interest free. It's remarkable. And, guess what? Every time you pay for new treatment, it restarts. You come in today, you get 2, 000 of treatment, you pay it off in 12 months. You come in next month You get another 1, 000 of treatment, well guess what, you get to pay it off in another 12 months, and it just resets.
So, really consider this, people are very gun shy, but you have to look at your life. How, how easy is it, how frequently do you charge your credit card and carry a balance? Uh, whether you want a new couch, you want to go on a trip, uh, if things are just, you know, times are tight, and you need to carry a balance, it's not all that unusual.
And when you carry a balance on a credit card, you're getting charged interest per month. When you carry it on third party financing, it's interest free with the right plans. So really think about that. What is your oral health care worth to you? If it's really important in your life, I highly recommend to get one of these accounts so you can afford the treatment that you need and pay it off in a way that is going to be financially beneficial for you.
So some offices, last thing, some offices will offer a painful discount or pay it time of scheduling discount for larger treatment plans. This is largely pretty, pretty frequent, pretty common. So ask your office if this is an option, the potential office you want to go to, and if it is, Fantastic. Uh, use that option, uh, get your treatment plan paid for.
Especially if you use something like Alfion. And they're paying, you know, you're paying, pre paying on Alfion, that total lump sum. Uh, you're gonna get a discount, that's awesome. So switching off of dental insurance may not save you money right away. But it will absolutely save you money in the long run, because you're going to be more focused on prevention, and treating the problem, and stopping the tooth death cycle, than continuing to chase your tail.
Parting thoughts, the reason why dental insurance is such a pain for the dental practice, and is becoming increasingly so, is because they make it very hard to get reimbursed. It is not unusual for a dental practice to have a lot of money that is uncollected because it's a constant battle with insurance to get the claims paid for.
Oh, we needed this image. Oh, we we didn't we didn't have that image. We needed another picture. We need another x ray. You didn't write the correct narrative. You gave us too much information. These are all games they'll play. Sometimes front office will sit on the phone, no joke, for an hour and if heaven forbid They help a patient check out, if that insurance agent on the other line says hello, picks it up, click, three seconds later, no one on the other line, okay, well now you gotta restart over, wait another hour and a half, two hours, thirty minutes to speak with someone, maybe just to collect two hundred dollars, and so then this ends up getting written off, because it's so hard to collect, so not only will you be helping yourself by parting ways with dental insurance, But you're going to be helping the office that you value going to, because they are going to get paid for the services that they render and be able to continue an operation.
If I had to wait on claims for insurance, and I was reimbursed, you know, 125, 200 for a filling that takes me two, two and a half hours because of my techniques, I would have shut my doors by now. I would not be able to stay open. I hope this has all been really helpful for you. Again, we're all sick here in the Clayton household, so if I rambled, repeated myself a lot, please forgive me.
But I wanted to drive home so many points that I tend to circle back to make sure you're understanding and you're on board with everything. I hope you have a great day, great evening, great morning. Whenever you listen to this, please send us a DM, leave us a review, send this podcast to someone, so that we can help get the word out and, and hopefully, in the long run, change the dental insurance market so it actually becomes Risk mitigation and rather than just a discount plan.
That's it for now. I hope you learned a lot on today's episode of Dentistry Disrupted. And I look forward to seeing you next time.
