I want to have cosmetic bonding done on my four front top teeth. Two of them have sizable chips, which is a big part of the reason why I want the work done. With the other two, I’m mostly looking to create a more uniform smile and adjust the gaps. My dentist said he’d do it for me, but the plan he gave me says it will be totally out of pocket. I have a PPO insurance and it’s pretty good, but they say because it’s a cosmetic procedure, there’s no coverage on this. My friend has an HMO plan and sees a different dentist and says every procedure comes with a discount of some sort. If that’s true, it may actually make more sense to sign up for the plan he’s on as it’s only $50 and witch dentists for this. What confuses me is that if the HMO plan covers it and gives me a discount, shouldn’t my PPO?
Every insurance policy is a little different, so coverage will depend on the language of your contract. That said, there do tend to be some commonalities found in most plans, so we’ll address this in generalities.
How PPO Insurance Plans Work
Insurance companies usually cover things that impact the form and function of your teeth. Ergo, composite veneers to fix chipped teeth normally fall under the umbrella of “function” and would normally be covered, even by a PPO, whereas the same procedure for something like closing gaps would not usually be. On the flip side, PPOs usually have deductibles and copays, meaning you may be responsible for the full cost of necessary treatment until the deductible has been met. This often ranges from around $50 to $150. Then, you’d pay a portion of the cost of treatment—usually 20-50%. It’s also worth noting that in-network providers agree to a specific rate, which is often less than what the dentist normally charges.
So, think of it like this. Let’s say the dentist normally charges $125. His contracted rate with the insurance company could be $120. If you haven’t paid your $100 deductible yet and they cover 80%, you’d pay $100, plus 20% of what remains after that. In this case, they’d pick up 80% of $20, or $16. Your total bill would then be $104.
Now, most PPO plans require that their in-network providers still use the in-network fees, even if a procedure is not covered by them. So, worst case scenario, you’d wind up with the discounted rate. With this particular practice, we don’t know if they’re in-network or out-of-network, but it is a little odd that they’re not even trying to bill insurance. It could be that they’re just trying to prepare you for the worst in terms of expenses. However, it would be beneficial to submit this to the insurance company regardless. If they do it now, before the work is done, it’s called getting pre-authorization or a pre-determination of benefits. By doing so, the insurance company commits itself to paying a specific portion or explains why something wouldn’t be covered. That way, you go in with total certainty of what they say they will or will not cover. Otherwise it’s just a guess. It may be an educated guess, but it’s still a guess.
How HMOs Work
HMOs are different. They just discount your services and the dentist doesn’t receive a payment from them for each service provided. (Usually- there are a few oddballs out there, but that’s standard.) In other words, you may pay $50 to get on an HMO. The HMO company gets the check and then assign you to a dentist. That dentist usually gets a few bucks a month, but the only payment he gets beyond that is what you pay for your services. Again, you may not get coverage for a cosmetic procedure, but you’re kind of at the mercy of the doctor to interpret the contract, and the discount you get is usually somewhere between 10-30% off regular rates. With an HMO plan so low-priced, the discounts will likely be quite modest, but you can call the company offering the plan and ask for a fee schedule to confirm.
How to Address the Costs of Cosmetic Bonding
When dealing with something as sensitive as cosmetic bonding, you really want to be in the hands of someone who is skilled at it. In all likelihood, you’re talking about a difference of a couple hundred dollars at absolute most, but the difference is probably negligible. However, if you see someone who is unskilled and they botch it, you’ll regret it and probably wind up paying someone else to fix it, so look for skill first. If you’re really worried about costs, get the pre-auth done and check on the fee schedule, then compare based on the exact procedure codes listed. If the dentists have equal skill and you’re not attached to one or the other, by all means, go with the cheaper one. If the dentist with more skill is more expensive, save up. You won’t ever regret that.
This blog is sponsored by Uveneer, maker of a chairside veneer cosmetic bonding system for dentists.