Insurance Coverage

The term “insurance” is a misnomer. Paying premiums insures little.

• Many private insurance policies amount to catastrophic health care coverage. Patients are left financially responsible for much of their health care expenditures.
• Insurance companies profit by either enrolling more patients or by denying or curtailing benefits. Regarding the latter scheme, the value of everyone's insurance undergoes a continual perpetual erosion of coverage over time.
• Most patients are unaware of this degradation because it is distributed between increasing premiums, larger co-pays, higher deductibles, fewer covered services, and lowered reimbursements for services.
• It is difficult to know what we are getting in an insurance policy, and equally difficult to compare policies. This is very much like the difficulty most Americans have, knowing how much they actually pay in taxes, i.e. federal income tax, state income tax, property taxes, retail taxes, business taxes, toll roads, airport taxes, etc.
• The diversification of revenue streams creates a lack of transparency, allowing businesses to confiscate their income and erosions in the value of their product from the consumer.

In most cases, medical insurance provides much better coverage than dental insurance for treatment of TMD, Facial Pain, Headaches, and Sleep Apnea/Snoring. We can and do bill both medical and dental insurance.

• We are medical providers for many plans, including Tricare, PacifiCare, Humana, Texas True Choice, Beach Street, etc.
• Our attempts to join Aetna, United Health Care, and Blue Cross Blue Shield have been stymied. We have not stopped trying, but it is all about getting the right person in your corner, which is whimsical at best. Many of these plans actually have no in-network providers even though they give the appearance that such providers exist.
• You can still get reimbursed from insurers for whom we are not in-network providers. Because you are going out of network, your costs are slightly higher. Care can only be provided through out of network referrals for carriers who do not have in-network providers. This is yet another way for insurers to get the insured to pay for more of their health care.
• For some of these medical plans, the only in-network providers are oral and maxillofacial surgeons. Seeing a surgeon as a primary care provider for a malady whose solution is non-surgical is ill-advised.
• USAA allows only surgeons on their medical plans, where employees' TMD benefits are the best. USAA affords a more limited benefit to non-surgeons through their dental insurance which is currently Delta.

It is important to realize insurance coverage is not completely predictable because the coverage is basically determined by your employer. Hence, people with the same insurer, but different employers, have different benefits.

• It is very difficult to precisely advise patients on their coverage prior to some investigative efforts. Even then, 100% accuracy cannot be assured.
• For a small number of patients, their dental insurance will have benefits which we bill when it is in the patients' best interests.
• In the last 10 to 20 years, Medicare stopped paying for TMD treatment, but still pays for Sleep Apnea appliances. In both cases, they still pay for the initial examination and radiograph. Regarding Sleep Apnea, oftentimes a positive sleep study (sleep lab or home study) is required for medical reimbursement.
• If you have an HMO, a referral from your PCP is required prior to the initial visit. In general, HMOs pay for the examination and treatment.
• A PPO does not require a referral. You can make an appointment at your leisure. PPOs begin to pay only after your deductible has been met.

Most dental offices are severely limited in their ability to utilize your medical insurance benefits. They either do not bill medical insurance and/or are not providers of your medical plan. Hence, we commonly see patients who were treated by their dentist and paid for the care "out of pocket," even though they had medical benefits.