I’ve been practicing dentistry for fourteen years, spending the first eight years in Arkansas, working in and then owning a practice that, for almost 100% of our patients, had contracts with their insurance as in-network providers. We also contracted with Arkansas and Oklahoma state Medicaid to provide dental care to Medicaid recipients. Many retired, elderly patients felt relieved to have Humana—and our office that contracted with it—since they had no employment to offer coverage. I still recall the day an older patient came to my office with a toothache. Since root canal treatment and restoration of the decayed tooth were on the table as viable treatment, she could reasonably expect to keep the tooth for the remainder of her natural life. But, she had no way to pay for that treatment and her insurance didn’t cover such treatment. Humana would only cover one simple filling per calendar year at a nominal reimbursement or an extraction at any time. Since she’d already used her allowed filling for the year, she opted to have the tooth removed. I knew she couldn’t afford to see an oral surgeon and pay their specialist fees for the extraction. I was her best hope for relieving pain. I’d removed enough teeth on geriatric patients to know that, considering what we could see on the x-ray, the extraction could prove difficult. But, wanting to help her, I proceeded.

Despite a difficult, time consuming extraction due to the quality of bone and root morphology, there were no complications. I remember she recovered well and was grateful for the care, skill, and judgement we provided. I appreciate when patients pay with gratitude. Unfortunately, none of my suppliers, landlords, creditors, tax collectors, or employees will accept gratitude as payment. The moment that shocked me was when my office manager told me how much Humana paid for the extraction procedure. We were contracted with them at that time to accept their payment and nothing more. The patient spent over an hour in my chair. If I broke down what I needed to produce hourly just to meet my monthly expenses before paying myself, I had to bring in about $450 per hour, if we worked at least 40 hours per week. My hygienists produced part of that, about $75-$100 per hour each. I had to produce at least $250-$300 myself.
Humana reimbursed us $62.

I operated then and continue to operate now on the idea that booking patients side by side for treatment is not in their best interest. I can only be in one place at a time. While extenuating circumstances may necessitate double-booking from time to time, it’s simply not a way of practicing that suits my temperament. I want to be able, when possible, to give all of my attention to a single patient. Their time is no less valuable than my own and my team and I do all we can to promote a relationship based approach to dentistry. Consider what Dr. L.D. Pankey, for whom the prestigious Pankey Institute in Key Biscayne, Florida is named, once said: “I’ve never seen a tooth walk into my office.“ Indeed, health care including dentistry is not a commodity-based business. While it is a business, what we are really selling to patients are our care, skill, and judgment. We have a fiduciary responsibility, backed up by personal integrity and a hippocratic oath that demand we put the patient’s interest above our own. If all we see is teeth walking into our office, relationships with patients suffer. For me, to over-book is a sure-fire way to turn my focus from patients to teeth. I refuse to work that way, even if insurance reimbursements seem okay with the idea if it improves their bottom line.

The insurance grind makes it easy to make teeth the focus of a dentist‘s attention. Their cut-throat reimbursements and clench-fisted claims processing have only their bottom line at the fore. A practitioner may be contracted with them, but that doesn’t mean that the Insurance Carrier feels an obligation to practitioners any more than it means the practitioner should think that they work for the Insurance Carrier. Anecdotal case in point: many offices accept assignment of benefits from the insurance company when a claim is filed. Insurance companies routinely hold payment for at least 30 days. (In the last two years, we’ve experienced this hold on payments being extended to 60 or 90 days as if it were a new policy from the companies.) In many cases, they deny claims for months. However, when the assignment of payment is made back to the patient, I’ve rarely heard of a patient waiting more than two weeks for reimbursement. Why? My explanation is that the patient pays premiums to the Insurance Carrier who DOES work for them. Businesses don’t want to bite the hand that feeds them. Thus, the dentist is simply easy to exploit in this way. We don’t pay them. We sign a contract to accept their reimbursement, and they have made it an industry standard to string us out until their investments have paid dividends before remitting their contractual payment.

Tying your hands to insurance benefits may not be in your best interest. Imagine you owned a car that you used every waking hour of every day. What if I told you that for $40 dollars per month, I would provide two oil changes on your car every year at 100% payment, and that you’d get a small discount on tire-rotations and car washes at participating service centers. Would you call that insurance or a maintenance plan? Well, this policy is really great! If your tires wear too fast, well pay once every five years to replace them. We’ll also pay a nominal reimbursement for other routine maintenance as a result of normal wear and tear. However, if there’s an oil leak or brake problem we won’t pay for anything until after it’s already broken. It may result in a breakdown on the highway and the need for a tow, but that’s not a covered benefit either. And, we’ll pay only $200 in repair costs in a calendar year. If the whole car breaks down, we’ll give your enough money to buy 50% of bicycle or some new shoes—but only up to your deductible of $200.

Often patients have little choice in what insurance coverage they have. The legal cost of fighting for benefits against a company that keeps large law firms on retainer is too costly for most people. While bad reviews against insurance companies can be made, the machinations of huge corporations that make us beholden to them, leave patients with little recourse. In contrast, a small medical or dental practice can’t afford bad press. Though we learn to be inured to it, I know few dentists who seem not to care about their fiduciary responsibility, and state licensing boards with power to review and penalize have resolute power of oversight. State boards have a legal mandate to protect people seeking medical care. And for the practitioner: again, most of the professionals I know are obsessed with creating favorable outcomes for their patients. They are wary of bad reviews which can damage a reputation quickly.

As constituted, dental insurance can never play a significant role in transforming significantly deteriorated oral conditions. It provides barely enough to help already healthy patients stay healthy. I’ve never seen an insurance policy that enabled a patient with extensive problems achieve anything close to rehabilitation of their oral condition. Even when it finally remits its meager deductible, the minuscule percentage of the treatment bill that it covers is a veritable drop in a bucket.
Despite the demoralizing nature of insurance and patient’s understandable dependence on it, insurance hasn’t yet destroyed the reason many of us entered the profession. From my interactions with colleagues, I am confident in saying that dentists and health care professionals care profoundly about the people we work for. We work FOR our patients. If you appreciate and trust your dentist, let them know it and reconsider the role insurance plays in your selection of your provider. We all want to provide the optimum of care for each individual. And while that may look different based on varied opinions amongst professionals, it almost never aligns with what your insurance is willing to cover and how much they are willing to reimburse for a job well done.