Dentists vs. Insurers: The Road Ahead

One evening after attending the ADA's annual session in San Francisco, Karen Gustin was chatting with a dentist on the shuttle bus to her hotel. When he found out Gustin was vice president of marketing for insurer Ameritas Group Dental and Eye Care, he asked the person next to him if he could trade seats. "It was a joke -- sort of," says Gustin.

It shows just how tenuous -- even adversarial -- the relationship between dentists and insurance companies is. But as current healthcare trends show, you can't avoid dealing with insurance companies. Soon, you'll be even more involved with them.

Gustin and other insurance industry panelists described how the dentist/insurer relationship will evolve in "An Inside View of Dental Benefits" presentation at the ADA conference, underwritten by the National Association of Dental Plans (NADP).

All the panelists stressed insurers value good relationships with dentists. Besides having dedicated provider relations staff, insurers have advisory panels composed of dentists. "We take your comments very seriously," says Gene Sherman, a former dentist turned chief operating officer of Starmount Life Insurance Co.

Why should you care?

It's in your best interest to track where dental plans are going, says Jon Seltenheim, senior vice-president of operations at United Concordia Companies. "Dentists should want more people to enroll because coverage overcomes the cost barrier, making people more likely to visit the dentist and more often, and have more dental procedures."

In 2004, $81 billion was spent on dental care, and insurers paid half of that tab. The NADP predicts expenditures will more than double, to $167 billion, by 2015. That's partly due to more Americans getting dental benefits. (In 2006, it was 176 million, 57 percent of the U.S. population.) Half the people with dental benefits belong to a dental Preferred Provider Organization, and 23 percent belong to a dental indemnity plan, but the latter is pricey and will keep declining in popularity.

Many dentists wonder why maximum annual benefits have not increased in the past 25 years. That's due to employers, who provide 96 percent of Americans' dental coverage, "Medical inflation limits dollars they can spend on dental coverage, so they keep looking for the most affordable options," says Seltenheim. "The medical side is what drives their agenda because it's so difficult to control."

New products and target markets

The NADP estimates 41 percent of employers change their dental plan solely because of rates. They're also making more employees contribute more out-of-pocket costs.

Insurers are coming up with new options to keep both groups on board, such as increasing maximums based on a person's overall wellness. One approach: "Rollover maximums," which roll over a portion of an employee's annual maximum to future years as long as the employee visits the dentist at least once a year. Insurers are also expanding coverage to include implants and sealants for more age groups.

With the large-employer market saturated, dental insurers are going after small businesses and individuals, particularly the uninsured, part-timers, and retiring Boomers whose dental costs are not covered by Medicare. Individual-coverage plans have doubled from 12 to 23 in the past three years, and the AARP recently announced its own dental plan, sponsored by Delta Dental. That doesn't mean individual plans won't be less cost-sensitive, says Gustin. "It's like the Burger King slogan ‘Have it your way.' That's what people want, but they'll still be sensitive to costs as more of the premium costs shift to their pocket."

Get your money fast

Insurance companies are also emphasizing electronic claim filing (39 percent of all carriers currently offer it) which pays dentists three times faster than snail mail. And no, insurers are not sitting on claims longer than usual to earn interest. "States require us to pay within 14, 21, or 28 days," says Sherman. "What holds payment up is when we don't get all the necessary documentation."

A dumb reminder -- but one many dental offices don't follow -- is filling out all the required fields on forms and X-rays. Submitting duplicate X-rays is a good idea but don't send Xeroxed copies of radiographs. "They're too hard to read, and that will hold up your claim even longer," says Sherman.

Narratives provide good information -- but use them judiciously, Sherman adds. "They're helpful if there are extenuating circumstances but they can also create delays. They can't be auto-adjudicated, meaning the processing computer will spit out a claim with a narrative for a human to review it."

Insurers have partnered with National Electronic Attachment to create FastLook, a one-stop web site that lets dentists see all insurers' guidelines for claim filing. Go to for details.

Future plans

The NADP is partnering with dental insurers on several initiatives, including a tax break for dentists upgrading their office equipment, the inclusion of dental coverage in Health Savings Accounts, and a national campaign to promote oral health literacy.

The latter is especially important said panel members, as the media discovers that poor oral health is linked to higher risks for heart disease, stroke, and Alzheimer's. "The dentist is usually the first to identify systemic health problems--120 disease symptoms can be detected in the mouth alone," says Doyle Williams, chief dental officer for insurer DentaQuest. "We can rally around this point to increase people's access to dental care."

Insurers are looking to tweak coverage after assessing a person's risk status, says Williams. "It will no longer be one-size-fits all. It will be linked to one's health risks."

To increase oral health, Williams predicts insurers will soon cover the following:

  • Chlorhexide mouth rinse after scaling and root planning
  • Prescription-strength fluoride toothpaste for adults after periodontal surgery
  • Sealants for a greater range of age groups
  • More treatments for pregnant women and diabetics

Looking down the road a ways, the NADP is sponsoring scientific studies of vaccines and stem-cell research for further oral-based treatments. For now, its biggest push is creating assessment tools to identify people at highest risk, so they can get more frequent prophylaxis, scaling, and root planning.

These efforts can only pay off for dentists, says Williams. If insurers can identify these patients and get them treated earlier, they'll realize they need insurance. That means, says Williams, they'll be in your office more often and be getting the care they need.

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