What do you do when you cannot afford expensive major dental work even though you have insurance to cover treatment?
Even the best dental plans have patient cost-sharing components such as deductibles, co-insurance, co-payments, and annual benefit maximums. Plus, some people chose out-of-network providers by mistake.
Left-over charges like these can bust your budget wide open. Fortunately, three strategies can help you avoid running out of money.
You can lower your out-of-pocket costs by phasing treatment over time, negotiating lower prices, and billing health insurance for medically necessary procedures.
Phase Expensive Work
Phasing treatment over time is the first thing patients with insurance should do to make major dental work more affordable. Rome was not built in a day. Likewise, your retooled smile does not happen in one appointment.
It takes time to heal in between each step, and labs might need to fabricate appliances such as crowns, dentures, and implants. Take advantage of the multi-stage nature of oral care to synch up with the plan year, buy supplemental coverage, and tap into flexible spending.
What do you do when you max out your dental insurance? Pushing the non-emergency-later-stage phases of treatments into the next plan year can dramatically reduce your out-of-pocket costs.
Most dental plans have an annual benefit maximum, which many expensive services easily exceed. In other words, the policy stops paying claims once you reach this limit but resumes on day one in the next plan year.
For example, follow this simple illustration of a patient needing $5,000 of dental work with a $1,500 annual maximum, whose plan year begins in January.
|Month||Insurance Pays||Patient Owes|
|Dec & Jan||$3,000||$2,000|
Purchasing supplemental dental insurance can help offset the high costs for the later-phase treatment steps. Supplemental plans make fixed payments based on the ADA billing code for each service and do not coordinate benefits with your existing primary coverage.
Supplemental plans often include waiting periods or graded benefits for restorative, endodontic, periodontic, prosthetic, orthodontic, and oral surgery services. However, your dentists cannot perform all of the work overnight.
Plus, people with oral health problems today often will have similar issues in the future. The extra coverage makes it easier to afford future copayments and deductibles.
Unreimbursed dental expenses (the amounts not paid by insurance) are tax-deductible on Schedule A. However; you must meet two thresholds before realizing any savings.
- All of your itemized deductions (medical and dental, local property taxes, mortgage interest, etc.) must exceed your standard deduction ($24,400 for married filing jointly, and $12,200 for single taxpayers)
- Unreimbursed medical and dental expenses must exceed 7.5% of adjusted gross income. Only the amounts above this figure yield any savings.
Flexible Spending Accounts (FSA) can make later-phase major dental work less expensive for patients regardless of whether they meet the Schedule A requirements. Elect to make a pretax payroll deduction into your FSA during the annual open enrollment.
Schedule an appointment with your dentist early in the FSA year to complete any remaining treatments. Charge the expense to your FSA, and your employer must honor the claim immediately.
- Get an interest free loan without a credit check
- Save money on federal, state, and FICA taxes
Negotiate with the Dentist
Negotiating with your provider is an excellent way for patients with insurance to make expensive major dental work more affordable. The fact that you have coverage in force gives you two critical bargaining chips to reduce prices.
Choosing an in-network provider is the most critical cost-saving tip for patients with insurance. Dental coverage often includes two components that make it cheaper for people to choose an office that participates with the plan – rather than one that simply accepts claim checks. Words matter.
- Better reimbursement levels for co-insurance means that the plan pays a higher percentage of the allowed charges for each service
- The allowed charge is the wholesale discount rate negotiated by the insurance company before you make your first appointment
Look at the explanation of benefits statement from a recent claim. Notice the enormous discrepancy between the provider charge (retail price) and the allowed amount (wholesale fee negotiated in advance).
An insurance company covering thousands of patients in your local area has greater bargaining leverage than you as an individual. Therefore, take advantage of scouring the directory of participating providers, and choosing an in-network dentist, periodontist, or orthodontist.
Dentists are more willing to offer you grants for restorative work such as implants, even though you have insurance. Many people mistakenly assume that pro bono services target only low-income patients without coverage when the opposite is true.
While purely altruistic providers do exist, far more are concerned with paying off student loans, or buying a bigger boat or a more beautiful vacation property. The fact that you have insurance already and require extensive treatment makes you a profitable customer.
Providers advertising dental implants grants are a case in point. They offer the free services only to patients with coverage for oral care – so they can bill your carrier for a host of related treatments.
Dentists want to fill their chairs with insured patients and are often willing to offer free stuff to get you in their office and keep you coming back year after year. Use this bargaining chip to full advantage.
Bill Medical Insurance
Billing medical insurance for medically necessary oral care is the final way to make treatment more affordable, even though you have dental insurance already. Healthcare policies leave patients with fewer unreimbursed expenses because they have no annual benefit maximums.
However, they do not pay for every service.
Private health insurance often covers medically necessary dental work. Have your practice manager bill the issuing company for any procedures that fit either of these definitions.
- The service treats an illness, non-biting injury, condition, disease, or its symptoms
- Incident to and an integral part of a covered service: part of the physician’s diagnosis or treatment of a non-biting accident or illness
The office manager should include a written narrative with the claim describing how your treatment fits one or both of these categories.
Oral surgery is the most expensive and most likely treatment that a health insurance plan might cover. Also, both types of coverage might pay on the claim and coordinate benefits: medical as primary and dental as secondary.
Oral surgery is more likely to fit the medically necessary category noted above because the operative procedures often treat an underlying disease, injury, or symptoms. Below are the most concrete examples.
- Extraction of bone-impacted wisdom teeth
- Reduction of jaw fractures following accidents
- Reconstruction of the jaw after radiation therapy for cancer