When we started the pediatric dental practice in Bellevue in 1974, there were really only a few dental insurance programs available to patients. We chose to become a member of Washington Dental Service Corporation (WDS), which was one of the first dental benefits company in the United States. WDS requires that we file our fees with them, and that we agree to charge the same fee to all patients regardless of their respective insurance coverage, and WDS will not accept fees if they are excessive. Additionally, WDS limits dentists’ increases relative to the Consumer Price Index (CPI).
Over the years, there have been different types of dental plans provided to patients, so we will try to explain the differences in the various plans.
TABLE OF ALLOWANCES
The patient pays claims based on a predetermined amount for each procedure. The patient then is responsible for any difference between what the fee is, and what the insurance company’s schedule of allowance says it will pay for a specific procedure. You, the parent, have the freedom to go where you want, without financial penalty.
PREFERRED PROVIDER ORGANIZATIONS (PPO’S)
The dentist signs a contract with the insurance company to be an “in-network” provider. This increases the dentist’s exposure to potential patients that also have contracts with the insurance company through their employers. To get in the network, the dentist is required to discount their fees to the insurance company. The discount is from 20-30 percent below the insurance company’s schedule of fees. In this contract, the dentist agrees to accept the discounted insurance company fees and no bill the patient for the remaining balance. The company claims 100% coverage, but in actuality, it is 100% of the discounted fee and not the true fee.
When a patient goes to a dentist out of network, the insurance company often isn’t all that concerned because it may save money by paying a lower reimbursement rate (sometimes even nothing at all) then they otherwise would have had the patient seen a dentist in network. The insurance company doesn’t have a contract with the out-of-network dentist. The savings are kept by the insurance company and eventually go to increase their bottom line. Unfortunately you, the parent, are penalized financially for seeing someone out of network even if you think the dentist is the best for your child.
Health Maintenance Organizations
These are provider networks that you have to go to get any coverage for services that are provided to you or your family. In this particular scenario, there are very few choices or locations for specialty care such as pediatric dentistry.
We have not joined more PPOs because we base our fees on the cost of doing business, and if we agree to charge one group of patients less, then we will need to shift that loss of income by increasing our fees to our other patients and their insurance companies. A number of our patients do not have the benefit of an employer paid dental plan let alone a dental plan of any kind. We feel it is wrong to have one group of patients pay more for the same service, so other patients’ insurance companies can pay less. Hopefully this explanation helps. If not, please ask us some more questions to help clarify this important topic.