How Dental Insurance Works

Dental insurance can be broken up into a bunch of different categories. There are HMO's, DHMO's, EPO's, PPO's, Medicaid/care, discount plans and I'm sure some others that I am unaware of. In our office we accept EPO's and PPO's in their various forms so I will spend the most time on those two.

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EPO- Exclusive Provider Organization: sounds special huh? What this comes down to is, your insurance provider enters into contracts with the dentist. These contracts provide a fee schedule to us requiring a specific amount to be paid as a co-pay. As a dentist, these types of plans compensate us the least for the procedure but they are the most clear cut in terms of co-pays... you come in pay the set amount and thats it. All the math and guessing is done for all parties. There are generally no "estimates" of what you will owe after insurance pays unless the insurance company flat out denies payment... which they always retain the right to do. Fortunately this happens in less than 1% of claims made. The biggest issue for patients with EPO plans is finding a dentist that accepts them. If you elect to see a dentist that is not "In-Network" with your EPO, insurance will not pay their part and you will be responsible for the entire amount.

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PPO- Preferred Provider Organization:  While it may sound fancy and that the insurance company has searched high and low for the best talent to provide you with the "Preferred Dentist" in the area, the title of "preferred provider" is an extremely misleading statement. The only thing that makes a dentist a "preferred provider" is their willingness to agree to lower fees than they would generally accept for a procedure. These fees are typically 25-35% lower than standard fees in the area. They dont screen us for proficiency or do anything else other than negotiate  lower fees. I know some extremely talented dentists that accept PPO's and I know some guys that I wouldn't let touch my worst enemy with a 10 foot pole that accept PPO's. 

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So how do PPO's work? PPO's collect a monthly fee from you in exchange for a list of dentists that are willing to accept these lower fees. Typically PPO's are offered by employers, although you can find them online or through private insurance companies. These plans vary widely in coverage and can be extremely difficult to understand. They all have an annual maximum typically between $500 and $2000. What the annual maximum does is provides a total amount that can be used on an annual basis.