Dental Insurance Secrets

Special Report

Nine Reasons You May Be Paying MORE at Your HMO Plan Dentist

By Michael I. Barr, D.D.S. of Palm Beach Smiles
Copyright Notice

 

If you are on a dental HMO or DMO plan, you may be shocked when you read what follows here.  Yes, it's a bit long and wordy, but I think you'll learn a lot or have some of your suspicions confirmed.

If you'd rather skip this intro and go straight to the meat of what's going on in the HMO world, click here to jump to the nine reasons you may be paying more under your HMO dental plan.

 An HMO or DMO plan requires you to choose your dentist from a list of contracted "providers" who have agreed to accept reduced fees.  However, you may not be saving as much money as you were promised.  You may even be paying MORE than if you had no plan at all.  How can that happen?  Read on! 

Have you gone to your "plan dentist" expecting to get your crown for the fee listed in your plan guide, only to find that the final cost is almost double or, in some cases more than double?  What happened to the bargain (50% off - or more) promised by your dental plan?  Read on!

You've had your teeth cleaned every six months.  So, when you show up at your new HMO / DMO dental office to get your "free" cleaning, you are surprised to find that you need "deep cleanings" that will cost you hundreds of dollars.  How is this possible?  Keep reading!

Here's what it comes down to:  Dentists can't afford to reduce their fees by 50% or more and stay in business.  Despite any noble intent, many find they could not stay in business if they actually charged the plan fees.  They would literally lose money.  So, dentists who sign on with HMOs and DMOs learn to "work the system."  They learn to add on fees that are "not covered" by the HMO plan.  They "unbundle" procedures and itemize "extras" that aren't really "extras" such as local anesthesia.  In a normal dental office, these "extras" are included as part of the procedure or service.  That's because they aren't really "extras."  By the time the HMO / DMO plan-recommended dentist is done adding on the "extra, non-insured" charges, the final fee is often MORE than it would be at a private dentist. 

Patients who sign up with HMO / DMO plans, under the expectation that they will be saving money, may actually end up spending more. 

So, why would a dentist agree to such an arrangement with an HMO / DMO?   By signing on as a contracted provider, the dentist gets a lot of patients referred to him or her by the HMO / DMO.  It's a promise to keep the dentist "busy."  They think they'll make up losses with volume.  Of course, it doesn't work out that way.

This report is not intended as an indictment of all HMO / DMO participating dentists.  This is only my opinion based on experience and observing my profession for the past 20 years.  But, I feel it's time these secrets are "outed."  This report is given freely without requiring you to send me your contact information as so many other "special reports" do. 

You should choose and receive your dental care with your "eyes wide open."  You shouldn't be surprised with unexpected costs.  Check out the "Nine Reasons You May Be Paying More" below, and see if any sound familiar to you.

When in doubt, get a second opinion.

Nine reasons you may be paying more at your HMO / DMO plan dentist:

(Click on each item to read more)

  1. "Deep Cleanings" (aka "scaling and root planing")

  2. Crowns (vs. fillings)

  3. Crown "Extras"

  4. "Surgical Extractions"

  5. Local Anesthesia

  6. Filling "Extras"

  7. In-house Specialists

  8. Unskilled, unlicensed dental providers

  9. Cheap offshore dental labs

 

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Deep Cleanings

This is also known as "scaling and root planing."  It is a legitimate dental treatment.  The question is:  When do you need it?  Deep cleanings are needed when there is calculus (or "tartar") beneath the gumline in the presence of "pockets" and inflammation.  A pocket is a separation of the gum tissue from the root of the tooth. 

For a proper diagnosis, before initiating deep cleanings, a thorough "periodontal probing" should be done.  Probing is simply measuring the depth of the pockets.  Generally speaking, pockets of 4 - 5 millimeters or more with bleeding (inflammation) and calculus are indicators for a deep cleaning.  Ask to see your periodontal probing chart. 

HMO / DMO dental offices can't afford to give away too many cleanings, so they find a way to generate more fees.  Unfortunately, I have seen new patients who were told they needed "deep cleanings" by their HMO / DMO plan dentist when they were not warranted, in my opinion. 

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Questions?  Click Here!

Crowns (vs. fillings)

Crowns are another legitimate and common dental service.  Crowns restore teeth that are too badly damaged for a filling to adequately repair.  When a tooth is damaged or previously filled to more than 50% of its original structure, a crown is usually warranted.  Since fillings generate extremely low fees in an HMO / DMO plan, the dentist may be discouraged from doing them even if they would adequately restore a damaged tooth.  Crowns generate a much higher fee, and it's easier to add on "extras" to a crown procedure.  Ask your dentist to show you the damage to your tooth and why a crown is needed.  You may very well need a crown.  Just don't be afraid to ask questions.

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Questions?  Click Here!

Crown "Extras"

This is where the HMO / DMO dentist can get really creative.  Your plan guide may say a crown should be $600, for example (fees vary by geography a bit).  And, that sounds like a great savings!  It's typically less than HALF of what the private dentists charge.  But, after it's all said and done, you may find the fee goes up quite a bit.  Getting a crown for the plan fee is often impossible.

The HMO / DMO dentist will typically add on a laundry list of non-covered charges such as:  precious metal, desensitizing, occlusal (bite) adjustments, Local Anesthesia, cord packing, temporary crown, porcelain, and more.  This is called "unbundling."  These items are not separate procedures, but rather they are just routine steps in the process that they are charging you for separately.  You won't find a private care dentist charging you extra for bite adjustments or anesthesia.  By the time you get to the bottom of the list of "extras," your crown fee may be double the fee listed in your plan guide.  You're paying the same cost as you would in a private care office, or MORE.  Where are the promised savings?  Why are you paying premiums for a plan that saves you nothing or may, in fact, be costing you MORE?

Try asking for only the crown your insurance plan covers / describes.  It doesn't exist!  At least that is what the plan dentist will try to explain to you.  The plan dentist will likely refuse to do a crown at the fee in your plan guide booklet.

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Questions?  Click Here!

Surgical Extractions

This is another perfectly legitimate service.  Sometimes teeth are beyond repair and need to be extracted.  There are routine (non-surgical) extractions, and there are surgical extractions.  A surgical extraction means that incisions were required or the tooth had to be taken out in multiple pieces.  Again, this is a legitimate and sometimes necessary approach.  Many times, however, teeth can be extracted without such additional measures.  In an HMO / DMO plan, routine extractions generate a very low and unprofitable fee.  So, I believe that many times, despite not being necessary, a "surgical extraction" is charged in an effort to eek out some profit for the service.  In the HMO office, EVERY extraction is a "surgical extraction."  Of course, that being the case is very unlikely.  Unfortunately, it is difficult for a patient to determine whether this procedure is indicated in their case or not.

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Questions?  Click Here!

Local Anesthesia

This is one that I have a hard time swallowing.  The HMO / DMO office charges you separately for local anesthesia!  It's just another way to squeeze out another $20, or so, of profit.  They add this charge on to any service that requires a local anesthetic and tell you your plan doesn't cover it.  In a normal private care office, you'll never be charged for local anesthesia, because it's normally INCLUDED. 

In fact, the American Dental Association's book of dental codes (Current Dental Terminology) specifically stipulates local anesthesia is not a separate treatment code during the course of routine treatment.

What's next?  A charge for the air you breathe?

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Questions?  Click Here!

Filling "Extras"

Fillings are a very common dental service.  You may find your HMO / DMO dental plan booklet lists fees that are substantially lower than the regular filling fees.  However, your HMO / DMO dentist can't afford to provide the service at less than 50% of the typical fee.  So, he or she must find ways to increase the fee with "non-covered" services such as:  bonding, pulp caps, occlusal (bite) adjustments, anesthesia, and more. 

One of these is a legitimate additional billable service - a pulp cap.  However, pulp caps are rarely done and typically when the cavity is so deep it just barely reaches the pulp (nerve) of the tooth and is on the border of needing root canal treatment.  My point of contention is when the HMO / DMO office reportedly does a pulp cap on EVERY filling to generate more fees.  It's just not likely. 

Bonding, bite adjustments, and anesthesia are just steps in every filling treatment and are not legitimate billable separate procedures.

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Questions?  Click Here!

In-house Specialists

Specialists are a very important part of dental care.  I refer patients to specialists often when their needs are beyond my abilities.  So, this report is not intended, in any way, to diminish the role of dental specialists in healthcare.  And, having in-house specialists is not, by itself, wrong in any way.  However, in my experience and observations, I believe specialists are often brought "in-house" at HMO / DMO-oriented practices to help the bottom line.  Here's how it works:

General dentists are qualified to provide "specialty" treatment such as root canals and extractions, for example.  It is up to the general dentist to decide when a particular case is within his or her comfort zone or abilities.  If a particular case is too difficult, the general dentist LEGITIMATELY refers to the specialist.  However, if the case is straightforward, there's no reason a general dentist can't provide the service unless he or she is not comfortable doing it.

But, there is a fly in the ointment when it comes to HMO / DMO plans.  The contracted fees for a root canal or extraction, if done by a GENERAL DENTIST, are VERY low - too low to be profitable.  And, there are few "extras" that can be added on to an extraction or root canal.  There is a loophole, though, with these plans.  A specialist can charge the "normal fee minus 25%."  How arbitrary is that???  So, the HMO / DMO practice can get around the dismally low fee that would be paid to a general dentist by hiring a specialist to do ALL OF THEM - even the less complex cases that could be done by a general dentist. 

If your HMO / DMO dentist refers you to the in-house specialist be sure to ask why, and find out what the fee for this service is going to be.

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Questions?  Click Here!

Unskilled, unlicensed dental providers

HMO / DMO practices may also allow their dental assistants to perform dental services illegally, including:  placing fillings, taking final impressions, and adjusting the bite on permanent restorations (fillings, dentures, bridges, and crowns).  These are quite obviously procedures that must be performed by properly trained doctors.  However, in a practice where mass production is the rule of the day, the dentist may be tempted to delegate some procedures to lesser-trained staff.  This way he or she can be more productive by treating multiple patients simultaneously.

Illegally delegating these procedures to untrained, unlicensed personnel may lead to all sorts of problems for patients, which is why in the state of Florida, only licensed dentists are allowed to perform these services.  If your dentist isn’t performing these services for you, you’re paying for and receiving illegal and unskilled care, and you are at significant risk.  Don't be afraid to ask questions.

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Cheap, off-shore dental labs

Like many industries, dental lab work (crowns, bridges, dentures) is increasingly out-sourced to underdeveloped, third-world countries with potential lack of sanitary controls, quality controls, and typically with inferior or even unknown materials and workmanship.  This may lead to breakage, gum issues due to improper contours, a lack of ideal seal - resulting in more chance of more tooth decay occurring, etc.  The advantage, of course, is cheap labor allows for very low lab fees.  This creates a significant savings to HMO / DMO dentists looking to cut costs. 

The obvious concern is a lack of regulatory oversight and quality control like exists in the United States.  You may have heard recent news reports about crowns made in China being tainted with lead.  Click here to read more.  Ask your dentist where your dental restorations are being made.

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More Information

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Copyright ©  2007  Michael I. Barr, D.D.S. & Palm Beach Smiles,  All rights reserved.
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