Insurance Predeterminations – Not The Crystal Ball You Think They Are

Insurance companies are often thought of as a necessary evil. When patients need dental care, they will often ask for a predetermination to find out how much their plan will cover. What patients might miss is the fact that often times the insurance company can be a burden, an opponent that we may have to lock horns with, and the predetermination is a great example of how this can play out.

A predetermination is often confused with a pre-authorization. The pre-authorization was done many years ago, and was replaced with a predetermination in the mid 80’s. A pre-authorization was in most cases a guarantee of payment. Patients often believe that a predetermination is a guarantee of how much the insurance will cover (although it isn’t) — that’s why they are willing to wait for it. Insurance companies see this as an opportunity.

Insurance companies begin with the goal of taking in more money in premiums that they are paying out in dental fees. Their goal is to limit dental treatment and pay for as little as possible, which means they are often working against the needs of both the dentist, and their patients.

The Potential Pitfalls of Pre-determinations:

It takes time.

This is often intentional, as it helps the insurance company make money. Patients often won’t commit to an appointment until they receive a predetermination, and in that time, patients slip through the cracks.

A patient may be in need of a crown that could stave off a root canal or tooth loss, but if it isn’t bringing them any pain, they may just forego treatment altogether, losing their sense of urgency after leaving your office. Insurance companies often want this to happen, as that is now a procedure they aren’t paying for.

It takes the dentist out of the decision making process.

In an ideal world, treatment will be between the dentist and the patient. If we decide to go the route of pre-determination, now a third party — with their own priorities — is rocking the boat. The insurance company usually isn’t in the business of looking out for the best interests of your patient.

If you seek a predetermination, the patient will usually base their decision on that information. The biggest problem with your patients basing their decisions on pre-determinations is…

Pre-determinations aren’t binding.

The biggest flaw with pre-determinations is that they don’t mean anything. Patients are forestalling treatment plans recommended by their providers to get a ballpark estimate of what the insurance company might decide to pay for.

Some plans might say they require pre-determinations, they can’t refuse treatment because of the absence of a predetermination. It is important for the patient to understand what they are (and how little they matter), in order to set realistic expectations.

Blog copied with permission from Sunrise Dental Solutions
written by: Linda O’Grady

Here They Are! The Answers to Your Most Frequently Asked Dental Questions.

Q: I was told I have a large filling that needs to be replaced with a crown. Why can’t you just replace the filling?
A: When a tooth becomes structurally flawed from decay, a failing filling or a fracture there is often little tooth material left to work with. A crown becomes necessary because filling material can’t be sculpted to replace large amounts of tooth structure resulting in a quick failure. The tooth must be protected by a crown which encapsulates the remaining tooth to fit like a “cap” to protect and preserve the tooth.
Q: Can’t you just pull my tooth if its bad? Why should I pay to fix it?
A: It is always best to retain your natural teeth as long as possible. Pulling a tooth may fix the immediate problem, but it sets you up for future problems that can be far more costly. The space of the lost tooth will allow adjacent teeth to tip into the hole. This will affect how all your teeth fit and work together. In addition, missing teeth are not esthetically pleasing. In the event you do have to pull a tooth as a last resort, it is best to replace it in a timely manner. Something like a dental implant will maintain the integrity of the surrounding bone structure and will act much like your natural tooth did.
Q: My dentist told me that my tooth ache required a root canal, but it doesn’t hurt anymore. Did it go away?
A: When the innermost part of a tooth is injured or infected debilitating pain can result. The pain is caused by damage to the nerve inside the tooth. Over time the nerve will lose vitality causing the pain to dissipate. During this process, however, toxins are released from inside the tooth and will ultimately result in a painful infection known as an abscess. The only way to resolve the issue is by removal of the nerve during a root canal.
Q: I was told I have cavities but I am too busy to come back for another appointment. What will happen if I just leave them?
A: The short answer is: they grow. The longer a cavity is left untreated, the weaker the tooth will become resulting in a larger filling than would have been necessary, or a crown. If the decay grows until it reaches the nerve a root canal will be necessary. It is always best to address dental issues when they are small and manageable. Allowing treatment to remain un-done almost always results in further pain and expense.
Q: I was told I need a night guard. Is that really necessary?
A: Tooth wear on biting surfaces is very common, and very damaging. People commonly clench and grind their teeth resulting in significant damage to their teeth, the temporomandibular joint and facial muscles. Clenching and grinding may cause teeth to break, become sensitive or infected. Pain in front of the ear and at the side of the face are common. Clicking and grinding noises in the jaw are also noticeable. Commonly a night guard provides relief of symptoms and prevention of further damage or wear.

Q: I have noticed my insurance won’t pay the full amount for white fillings on my back teeth. Is it worth the extra money to have white fillings?
A: The benefit of filling teeth with white (resin) fillings instead of silver (amalgam) fillings is well worth the few extra dollars it will cost you. An amalgam filling requires far more healthy tooth structure be removed, while a resin filling can be done much more conservatively preserving the structural integrity of your tooth. A resin filling will actually help to strengthen your tooth as opposed to weakening it. There is always the controversy over the mercury contained in amalgam fillings to consider. There is some research that suggests the mercury can leak out and can affect your overall health.

Financial Solutions for Un-Insured Patients

Dr. Glass recognizes there is a need in our community to offer affordable solutions to our patients who may not have dental insurance. The importance of good dental care should not be overshadowed by the costs. Many un-insured patients feel their only choice is the large chain dental offices.  While that may work for some patients, many people would rather have the personalized experience that only a private practice can offer. We can make that happen! We would like to familiarize you with the various solutions we have for our patients who do not have dental insurance.Our Membership Program enables patients to get the care they need at prices they can afford even without dental insurance.

Patients who enroll in the Membership Program are entitled to:

  • No deductibles
  • No pre-existing limitations
  • No yearly maximums
  • No claims forms
  • No pre-authorizations

The yearly membership rate covers common dental procedures patients need to maintain the best oral health, including two dental cleanings per year, unlimited oral exams, a comprehensive periodontal evaluation, an intraoral camera exam and unlimited digital X-rays. The cost of these visits can range anywhere from $309.00-$500.00 and more per year, so you’ll see the value of your membership in your pocket immediately! 

Patients in the Membership Program also benefit from reduced fees for additional dental cleanings, cosmetic procedures, emergency office visits, general dentistry procedures and periodontal care should they develop gum issues. These services are available to program members at a 15 percent discount.

To help you receive the dental care you need that will fit into your budget, in addition to enjoying discounted rates our members enjoy an extended payment plan if they need it. Our office policy is to extend credit out 3 months, but for our patients enrolled in the Membership program, we can extend the payment plan term to 6 months with no interest.

The cost of enrolling in the Membership Program is just $299.00 per year for adults the first year, then a $249.00 renewal fee every year after. Children under the age of 13 are only $149.00 per year. Your membership period begins as soon as we receive your fees so you can immediately get the services you need at a reduced cost.

The Membership Program is specifically designed for patients who have no dental insurance. It cannot be combined with another dental plan or insurance, and the program cannot be used for services performed for injuries covered through automobile or medical insurance or workman’s compensation. For more specific details go to our membership tab at

If you have no dental insurance, enroll in the Membership Program today to get the care you need at prices you can afford! The team at Walter Glass Dentistry is glad to provide flexible and affordable options for our patients and happy, healthy smiles in the process.

For our patients that choose not to purchase the 12 month membership, or who would like to extend their payments out beyond the 6 month period, we can offer Care Credit and Citi Health Card. Both are credit cards that are used for medical purposes only and will allow you to finance your dental work for 12 months at 0% interest. They are both managed by a credit card company outside of our office and can most likely be used at your other medical services providers as well.

We also have a referral program, for every new patient that you refer to our office you will EACH receive a $75.00 credit to your account to spend on your dental treatment. This is even applicable to immediate family members, so there is no excuse not to bring the family with you when you come in!

If you have questions about these programs, or other ways we can help make your dental care fit into your budget more easily, please call our office at 303-979-4981 to discuss your options. We believe that quality dental care in an office that can provide high calibur, personalized dental treatments should be an affordable option for everyone, and we are proud to be the office that can offer you real solutions!

Dental Insurance – Sorting It All Out

The role your dentist plays in maintaining your oral health is easy to understand; however, the role of dental benefits is sometimes unclear. Insurance industry jargon used to describe your benefits often blurs the actual terms of coverage, and what is covered under one plan, might be excluded under another plan.  We encourage you to be informed on how your dental benefit plan works so that you can make the most of your coverage.  Dental benefit plans help you pay for certain kinds of dental care. Your dental care decisions should take into account more than just what is covered. Your dental health needs can only be determined through consultation with your personal dentist. Good dental care is your right, and can best be attained by understanding your specific dental needs and how your dental benefits plan relates to them.

There are many different types of insurance plans, and one of the most common misconceptions about dental insurance is the expectation that the policy will pay in much the same way that a medical plan would pay. This is simply not the case. Dental insurance is subject to yearly maximums, frequency limitations, and the limitations of usual and customary fee schedules. So what does this mean? A Usual and Customary fee is a fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area. The UCR allowance may vary from company to company. While these reimbursements usually are based on what the majority of dentists in your area charge, sometimes the figures used to calculate benefits may be out of date or not specific to your location. Furthermore, if the company uses a Table of Allowances, benefits assigned to specific dental treatment may not relate to actual costs. Many insurance companies also have a Least Expensive Alternate Treatment clause. The insurance company’s contractual arrangement with the policyholder allows the insurance company to substitute a less expensive, but in the insurance company’s opinion, professionally adequate service which reduces the amount the dentist is reimbursed for your treatment.

Many employers will contract with a closed panel or preferred provider program to contain the costs of insuring employees. As a result, your dental benefits might only be available by seeking care from a dentist who has contracted with that company. A PPO or Preferred Provider Organization  is a group of dentists who have contracted with an insurance company to provide care at discounted fees. (“Preferred” refers to a dentist who has contractually agreed to provide services at discounted fees.)  Dentists who are “in-network” have agreed to a personal contract with a benefit plan. These contracts have restrictions and requirements and usually dictate adherence to a reduced fee schedule. Therefore, patients who chose an “in-network” dentist typically will pay less of their own money toward treatment than those who choose an “out-of-network” dentist, but their treatment could be dictated by what the insurance company considers adequate treatment for your particular condition. 

An “out-of-network” dentist has not signed a contract with the insurer of a particular plan. However, patients may still choose that dentist and have some of their fees covered, but they may pay more out-of-pocket. These dentists are free to prescribe the treatment they feel is best for your dental condition without the confinements of a particular insurance policy. Dr. Glass is a participating dentist in some insurance plans that allow him the freedom to practice dentistry without compromising the quality of care he provides. His office staff are experts at helping you maximize your benefits, both in network and out of network.

Bottom line, it is important that you receive regular dental care from an ethical and thorough Dentist that you trust without letting your insurance company dictate the type of treatment you will receive.