INSURANCE: What it is and what it isn’t.

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We often become frustrated when we recommend valuable treatment to clients that is not fully reimbursed by insurance. Common complaints from clients include “Insurance doesn’t cover it,” and “I don’t have insurance.” Despite this obstacle, we should not avoid recommending treatment. Instead, our dental hygiene role as educator should help us explain how patients can get the most out of insurance, yet how it is limited.

People view health insurance as the exclusive way of paying for health care. There is an implicit assumption that health care is expensive, that insurance companies determine standard of care and who may provide that care, and that they approve or deny treatment.

Health care is not expensive

Contrary to the first assumption, health care is not expensive. If that statement surprises you, think about the primary goal of your clinical work as a dental hygienist. Clients who visit you regularly for prophylaxis usually need very little treatment beyond that. That’s the whole point of prophylaxis - prevention of disease. Much of our time and effort goes into educating clients to take care of themselves through prevention. You might be thinking that most people need more than a prophylaxis. Many have periodontal disease, dental caries, or more complex problems that need a physician’s care. Those problems are not “health care.” They are “disease care,” which is what insurance is supposed to help people with when preventive health care isn’t enough. Disease care is the expensive problem.

Why should there be a distinction between health care and disease care? First, knowledgeable clients seek care in greater numbers to maintain health rather than to fix a disease, and dental hygienists are in a perfect position to cater to these people. By providing simple, preventive care, we help people save time and money while improving their quality of life and reducing the burden on disease-oriented professionals. Practitioners often spend too much time on people who have neglected their health. Their time could be better utilized providing treatment in emergencies and the early stages of disease, and on elective treatment that can improve quality of life.

Second, health care has a different philosophical focus than disease care. When people who approach us with no problems want to stay healthy, they are more inclined to take an active role in their care. Then we professionals have the luxury of providing care on an acceptance rather than needs basis.

Finally, health care is distinguished from disease care by the way insurance helps. Unfortunately, insurance is rarely used in a way that spares people from the cost and headaches from which they expect insurance to protect them. Ideally, insurance is designed to protect people from major financial loss. Consider car insurance. People buy cars with the knowledge that they might be in an accident or a hailstorm, which could cause them to lose much of the value of the car. They buy insurance to protect them from that loss. However, insurance doesn’t protect them from the most common loss of car value - depreciation. Why? Depreciation is an expected loss in owning a car.

Also, people might have a warranty, which is a form of insurance that protects them when the car breaks down sooner than its expected lifetime. Warranties often become void if people do not keep up with the preventive care. Why should insurance companies reimburse people for damage caused by neglect? Unfortunately, that is the state of most medical and dental insurance plans, and health-care providers have been encouraging that neglect. We tell people their insurance is good when it “covers” all of the prophylaxis fee and most of the major treatment fees. If we think about where that coverage comes from - the premium - we note that the consumer is not getting good value and is being conditioned to underestimate the value of preventive health care. Instead of providing financial security, insurance gives consumers a false sense of security that everything will be taken care of, and they are paying a fortune for it.

Standard of care in our hands

People often let insurance coverage determine whether or not they accept treatment. Worse, we professionals often let coverage determine whether we offer treatment. Many people think that only covered procedures performed by dentists or physicians signed up with a network are worth doing.

However, if we stop looking at insurance companies as entities that pay for our services and instead look at them as they were intended - as companies that protect from financial disaster - we put power into the consumers’ hands. Ultimately, insurance coverage is a contract between the consumer and the insurance company. Yet many consumers have the false sense that insurance agents have expertise in health care and know which practitioners are best for particular procedures.

When insurance companies send clients denial of claims letters, they often refer to experts who decided that the recommended treatment did not fit the necessary criteria. However, the experts use criteria determined by the insurance companies, which profit when they do not indemnify a claim.

Neither the insurance company nor the experts are liable for a client’s resulting condition, as we are. Nobody at the insurance company has performed the diagnostic work that makes an expert’s opinion valid. A clinician looked in the person’s mouth, probed, and took X-rays related to oral health and the treatment outcome. Click here to view "Table 1 — Insurance Definitions"

Insurance companies handle managed care, so we and our clients often view managed care as insurance, and this form of financing has even more influence on our treatment recommendations. Managed-care programs, such as health maintenance organizations (HMOs), are discount plans. Payments for services are out-of-pocket for the client.

Preferred provider organizations (PPOs) similarly offer providers contracted fees, but typically offer some indemnity for services rendered. Clients who pay a fee to be eligible for the discount plan receive contracted fees that are usually lower than the practitioner’s nominal fee. In return for accepting those contracted fees as full payment, the practitioner receives a small reimbursement. The practitioner also receives marketing by being on a list of contracted providers and having clients assigned to the office.

We must resist the urge to second-guess ourselves when insurance covers less than our recommendations. Adopt the attitude, “If you trust the insurance company more than me, why are you here?”

Approval of treatment

Insurance companies cannot approve or deny treatment. They can only approve or deny indemnity within the guidelines of their policies. Yet, insurance companies have been mailing “treatment authorizations” for pretreatment estimates for many years.

Have our clients and we become so complacent that we let an outside company decide which treatment is correct? I see people decline treatment nearly every day with the excuse that their insurance doesn’t cover it. I see practitioners fail to offer valuable services because they are afraid the out-of-pocket cost will scare away the client, and I see administrative personnel telling people their insurance company “doesn’t allow” a procedure.

Educate clients

Dental hygienists are in a great position to educate clients about the misinformation, misuse, and value of insurance. However, we must first understand it. Please do not keep quiet when people use insurance as an excuse to decline treatment. Instead, the explanations in Table 1 can help persuade clients toward preventive care.

Our compassionate nature can make us uncomfortable accepting clients’ hard-earned money for the work we do. In the long run, however, dental hygienists save clients money by preventing more expensive needs. We should proudly accept the relatively small remuneration for the valuable services of prevention and early treatment. When we take that pride, we can confidently say we’re worth it, with or without insurance.