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Why Dentists Go In And Out Of Network

When you purchase dental insurance or your employer provides it, it’s usually a plan that is referred to as a “preferred provider organization” or PPO plan.  A PPO plan finds dentists that will agree to charge an agreed upon amount for any given procedure.  They cannot charge more…the fee has been set already.  This creates a network of dentists that have agreed to charge a lower, agreed upon fee.  Those dentists are “in-network” with the insurance plan.

Why would a dental office not participate in these networks?   There are a few reasons.  Some offices are in areas with little competition so there is no need to sign up with these plans to attract patients.  Or they have built a large following and now have no need to agree to a fee schedule.  Their patients are fine paying what the dentist charges as they don’t want to go anywhere else.  Some offices have built a niche of performing cosmetic dentistry.  These offices focus on people who want a lot of cosmetic work done and insurance rarely pays for those procedures anyway.  There is no benefit to sign up with these plans.

But there is a more common reason why offices may not be in network.  What the general public does not know is that these plans can very widely in what they pay the dentist and staff.  Some plans pay quite well- at or near what a dentist would usually charge.  Some plans are not so good.  And some are downright terrible in what they reimburse the dental office.

All businesses need to operate on a profit.  If the insurance company pays the dentist or hygienist just above what it costs them to provide the service, why would they bother?  Or why would they GO IN DEBT to provide the service?  It is true- several plans pay so little that the provider would be paying for the opportunity to do them.

Everyone thinks dentistry is expensive.  I doubt dentists will get any sympathy about not being reimbursed enough.  There is still a cultural myth of dentists and physicians being millionaires and being on the golf course when they aren’t at the office.  The money just flows in.  You can believe what you want but no dentist or physician I know owns those multi-million dollar buildings downtown.  I know who does, though.

At Plainfield Dental, we are in-network with many insurance companies.  We understand cost is a major factor in getting treatment.  A business should be efficient and there should be pressure to keep costs down for patients.  Competition is good for the patient.  We always strive to be competitive and if we can give high quality care at the fees your insurance company allows, we are in network with them.  But some insurance companies reimburse so little that we would have to compromise on the care we provide.  And that won’t happen.  There has to be a balance.

Also, one last note.  We have noticed that when we accept insurance but aren’t in-network (you can usually use your benefits at any dental office regardless if they are in-network or not), we have noticed that the out of pocket expenses for the patient may not change or the change is minimal.   It’s up to you to determine if that small change is worth it.

Who Owns Your Dental Office?

Dentistry is currently experiencing a paradigm shift that occurred in medicine about 15 to 20 years ago.  In the past, medical doctors owned their businesses.  Through the monopolization of hospitals and influence of private investment, most of our nation’s doctors have had to give up their private practices and become employees of large corporations.  Gone are the days of the local doctor who did house calls and personally oversaw everything in his practice.  Today, doctors are employees of large groups or hospitals that are usually owned by wall street and private investment firms.  And those investors only care about one thing- the return on their investment.

To put it simply, your health is essentially determined by investors and insurance companies.  The actual input from your doctor into this equation gets minimized every year.  Don’t believe me?  Just ask your doctor.  Job dissatisfaction is at an all time high and there are now news stories of doctors “going on strike” in various parts of the country.  This was unheard of in the history of the United States.

These outside influences have moved into dentistry.  Large investment groups see dentistry as an untapped market for profit… profit that they feel entitled to.  I have seen that several dental offices in the Plainfield area have sold their ownership to these outside corporations.  The dentists are now employees and do not have the final word (regardless of what they may say) of what goes on in their practices.  They are employees… they have no voting power in what ultimately happens in their offices.  The investors make the final decisions.

Another thing to remember is that when an office is sold to a large corporation, the profits of those offices are now funneled to wherever that corporation is located.  It could be several states over.  It may even be overseas.  This has a real impact on the local community.  Money brought in by locally-owned businesses tends to stay in the community and neighboring communities.

At Plainfield Dental, my partner and I own the office.  The buck stops with us in regard to what happens inside our office.  We have total control over our treatment recommendations (what insurance wants to pay for is a separate matter…a topic for another day).  We have no pressure to satisfy anyone but our patients.  We have no investors looking over our shoulders.

Corporations are not bad.  I love Costco and I buy from Amazon.  There is a place for them.  But their place is not everywhere.  Small businesses need to thrive for the health of the economy and for the health of patients, doctors should own them.

As long as I’m practicing dentistry, our office will always be owned BY DOCTORS.

A Message For Our Delta Dental Patients

Because we value you as a patient, we would like you to hear from us personally that we have decided to alter our participation with Delta Dental.   As of May 1, 2024 we will become a Delta Dental Premier provider.  

What does this mean to you?  Perhaps nothing.  Most of our patients have a PPO/Premier option plan.  Your claims will be processed under the Premier fee schedule.  

However, there may be a small percentage of our patients with a Delta Dental PPO only plan.  In this case, you will be able to continue your dental care with us but depending on your plan or group, your out-of-pocket responsibility may be slightly higher.   

We encourage you to reach out and talk with our team members if you have questions. 

Sincerely, 

Dr. William Peck 

Dr. William Madison 

Dr. Peter Muraglia 

Dr. John Planisek 

The Hygienist Pulled My Filling Out.

Every so often, we will have a patient that is receiving a dental cleaning and a filling or crown will come loose or fall out.  Sometimes, the patient believes it is the fault of the hygienist doing the cleaning.  The hygienist was either being too rough or not cleaning properly or somehow it was the fault of the dental office to have caused this.  Let’s put this idea to rest.

All dental work (and natural teeth, for that matter) should withstand a professional dental cleaning.  If a crown or filling comes loose during a cleaning visit, it needs to be redone or recemented.  It was faulty prior to the appointment.  It is impossible for dental cleaning instruments to pull out properly done fillings and crowns.  You need not worry that a professional cleaning will harm your dentistry.

Usually, the only thing keeping a bad filling in place is that it’s wedged between the teeth.  During the cleaning, the loose/broken/decayed filling becomes free.  And in the situation of a crown coming loose, the cement is no longer serving its purpose and the crown needs to be recemented with new cement.

If your filling or crown comes out during a dental cleaning, I can’t think of a more opportune time for it to happen.  The hygienist and dentist are right there to address it.  So if this happens to you in the future, be thankful it happened in the dental office and not while on vacation.

Craftsmanship

Dentistry is where medicine and carpentry intersect. The doctor is a craftsman as well as a surgeon. Surgery is defined as cutting body structures to cure disease and/or mend injuries. Dental fillings and crowns are surgery. A surgery that involves measuring, cutting/drilling, gluing, shaping, polishing…the same steps a carpenter or cabinet maker does on a daily basis. In fact, many dentists are woodworkers and model builders in their spare time.

Today, insurance companies and the marketing industry are doing their best to make every dentist appear the same. Are all carpenters the same? Any craftsman for that matter?  No. And dentists are no different.  We all exist on a bell curve of quality, from great to good to barely acceptable.  A license to practice only means a minimum standard was met (and after graduation, some start slipping under that standard).   Luckily in the US, most are on the good to great side of the bell curve.

Seek out a dentist that sees themselves as a doctor and a craftsman. One that takes pride not only in their diagnosis, but also in the service and product they deliver.

Should you be concerned who owns a dental practice?

The below link is a good article on the issue of private investing firms making their way into health care.  Medicine has had to deal with this longer than dentistry but dentistry has been infiltrated and we are dealing with the same issues.  Many dental practices are already run by investment firms and nondoctors.  Who do you think does a better job of looking out for the patient? A doctor or an investor looking to get a good return on their investment?  The below article will explain the conflict of interest there.

In case you’re wondering, we (the doctors) own our practice and all treatment decisions are made by us.

http://www.dentistrytoday.com/news/todays-dental-news/item/3574-physician-groups-challenge-corporatization-of-healthcare

Dentist awards and other marketing gimmicks

Have you ever visited a dentist that had an award on his or her wall that said they are a “top dentist”? Were they nominated as being one of the “best” dentists in the area and have a plaque to show for it?  Ask them who voted.  Did you vote?  Some of these awards may be legitimate.  For instance, local newspapers will run a contest where patients can vote for their favorite doctor.  But most of these things are phony paid advertisements.

I frequently get solicitations that I’ve been nominated/voted as a “top dentist” from some ambiguous company.  For a fee, they’ll send me a fancy plaque to mount in my office.  The only apparent requirements for this prestigious award was that I graduated from dental school, have a pulse and a credit card number.

I see this as just another way professionals are eroding away the trust that society has given us.  If you can pay for these awards, shouldn’t you disclose that? If you legitimately won an award, great.  Let your patients know.  But if you paid for the award to impress others, that’s kind of sad.

3 Dental Habits That Will Save You A Lot of Money and Discomfort

Habit 1 is obvious:  brush at least 2 times a day, preferably with a fluoride toothpaste.  Some say brush after every meal.  I don’t even do that.  If you can brush after breakfast and before bed, that would make most dentists and hygienists happy.

Habit 2 is also pretty obvious but is done way, way less then Habit 1.  That’s flossing.  At least 80% of what I fix is decay between teeth.  Maybe more.  Nobody really likes to floss.  It’s much more tedious than brushing.  But it pays much larger dividends to floss.  Not only do most cavities start between teeth, most gum disease starts between teeth as well.  It would be nice to floss twice a day just like brushing.  The more the better.  But if you can at least floss every day before bed, that’ll go a long way to improving your dental health.

Brushing and flossing protect you from bacterial and chemical attacks to your teeth and gums.  But your mouth can also be under attack from excessive mechanical/chewing forces.  That’s where Habit 3 comes in:  wearing an occlusal guard.  Call it a night guard, grinding guard, occlusal guard, clenching guard, mouthpiece if you want but they are all similar and usually look like this:

Not all patients need Habit 3 but I’m going to say the number that do are now in the majority.  I’m not sure if we’re more stressed today or perhaps we’re better at detecting the signs and symptoms that require an occlusal guard.  Let’s look at some teeth that would benefit from a guard:

Do your teeth look like these?  This patient grinds their teeth.  Unless they are going in there and using an emory board or metal file, there is no way teeth get flat like that from normal chewing, especially in a younger patient.  Something else is going on here.  And if it’s not caught early, you can end up looking like this:

When it gets to this stage, it’s the cost of a Cadillac to fix.  All the teeth need to be crowned to regain the height they once were.

An occlusal guard protects not only the grinders but the clenchers.  Clenching is harder to detect.  There is minimal tooth wear.  But you may be having vague pain that is not traced to a cavity or broken tooth.  Another telltale sign is losing gum tissue and tooth material right at the gum line:

When you clench your teeth, your teeth flex.  Teeth are like marble and they are not designed to flex.  Marble chips.  So do teeth.  Also, the body doesn’t like this force and pulls the gum and bone tissue away.  That’s bad because gum and bone are the only things holding your teeth in your mouth.  Trying to regain gum and bone requires expensive surgery to fix.

In summary:  brush, floss and put your guard in when you go to bed (or during the day if you catch yourself grinding or clenching).  Your mouth and wallet will thank you.

(all photos obtained via Google Image search)

“My last dentist says I have 5 cavities, you say I have 6 (or 4)”

Dentistry is so hard to diagnose decay sometimes. There it is. The truth. In dental school, we were taught that if our little hook thingy (the “explorer”) stuck in a groove, it was a cavity. Didn’t matter if it looked dark or not. We were also taught that cavities on the flossing side of the tooth should be treated when they reached the softer, inner part of the tooth (the “dentin”). Oh, if only diagnosing decay were that easy…

The older and more experience I get, the more I realize that dentistry can be one big shade of gray. Diagnosing is changing. I’ve opened up teeth with a little stain on them to find HUGE mushy decay underneath! I only opened them on a hunch based on the patient’s diet, home care, etc. I’m glad I did!  Otherwise, a root canal and crown would have been needed in 6 months. The problem in dentistry is that sticky grooves and x rays are not fool proof. There are many other things to be considered.  Some docs are up to speed on this, some are not. And no matter how many factors you look at, there will always be some ambiguity.

When I see a patient for a second opinion, I really want to try to diagnose the same amount of cavities as the previous doctor. I really do! It just makes it less awkward for everyone involved. Of course, I have to be honest and have a reason of some sort to diagnose a cavity on a tooth. What happens though is sometimes I don’t arrive at the right number. There are usually a couple “gray area” teeth that could have cavities or not…I’m not sure!   Here’s the funny thing. If I diagnose less, the patient almost always stays with me. But sometimes that other doctor knew something about you that made his treatment plan a little more aggressive. And sure enough those “gray area” teeth need to be treated in 6 months or so. Such is the nature of diagnosing cavities.

Let’s talk about the elephant in the room. You’re coming to see me for a second opinion because you don’t trust your last doctor. That’s the only reason. Okay, maybe the second reason is that she or he is really expensive. But you’re probably afraid he is diagnosing things that are really not there to make money. Guess what? This for sure happens. There are some treatment plans I see where this is obvious. But really it’s not that common. Most treatment plans I see are pretty fair. Yes, some teeth can go either way and I try to explain this to the patient. I’m sure people left me for the exact same reason so I try to be aware and explain the subjective nature of dentistry. You never want to bad mouth another doctor as you rarely have all the information and eating crow tastes terrible.

Here’s something else to think about. Moving around offices until you land in Dr. Not Looking’s office is not a very good strategy either. It does no good for a dentist to “watch” everything until it turns into 5 root canals and 5 crowns for $10,000. Did you really come out ahead on that deal?

In dentistry, you have to trust your doctor. You have to realize that there is a subjective, ambigious nature to much of dentistry.   But you need to know that your doctor is trying to navigate this with your best interests in mind. It seems the older I get, the more shades of gray I see.

Does “Do you take my insurance?” equal “Are you in-network?”

Do you think the above means the same thing? Most patients do. But it really does not. When you call a dental office and ask, “Do you take my insurance?” without asking any additional questions, almost 100% of the time they will say “Yes”. But are you and that office agreeing on what that means?

Let’s define some things. “Taking insurance” just means that the dental office will file a claim to your insurance on your behalf. They are free to charge what they want and what is not covered by your insurance, you pay. They are not tied to any fees dictated by the insurance company.

What does “in-network” mean? It means that your insurance company has already negotiated the fees on your behalf and that is all the dental office can charge. Usually, this means it’s more affordable for you. I say usually because there are some shenanigans that offices pull in order to charge you more than necessary but that’s for another article. But generally, you pay less.

So, was the office you went to lying when they said they took your insurance but after a few visits you realize that they were not in-network? No. But it might be a good public relations move for these offices to explain the differences on the front end. In their defense, you’re ultimately responsible for what plan you purchased. Dental offices are not obligated to walk you through your insurance plan. But we usually do it as a courtesy.  Dental plans are incredibly confusing (even for us and we deal with them daily).

Here’s another thing I hear: “I wasn’t allowed to go to my last dentist because he is out of network”. Not true! If you liked the guy and the staff, you can still go there! The insurance company police will not track you down and throw you in jail! Unless you made a radical change (like going from a PPO to and HMO), you can still see the doctor you like and use your dental benefits. Yes, you may pay a few bucks more but it may be worth it to you!

Why wouldn’t all offices be in-network? Because some insurance plans are just plain lousy. To be profitable, the dentist would have to cut corners on your actual treatment or schedule you next to ten other people and you get to wait an hour to be seen.   People think that healthcare is immune to basic economic principles. It is not. In healthcare, just like everywhere else, you get what you pay for.

We are in-network with many plans that allow us to do top quality work at reasonable fees. But we are not in all the plans for the reasons above. We occasionally drop plans and add some plans. The nice thing about dentistry in the US is that you have to freedom (still) to see any doctor you want. domain list . You may have to pay a little more, but if you like the doctor and staff, it’s well worth it.

In conclusion, if being in-network is very important to you, then ask, “Are you in-network?” In our office, this is sorted with the first phone call.