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FAQ Doctor to Patient Communication Regarding Dental Plan Coverage

April 28, 2023 563

This guide was developed to help with patient discussions about their dental benefit plan, both for those dentists who participate in the patient’s dental plan and those who are not contracted plan providers. This is not intended to be a patient-facing resource.                   

Q: I recently terminated my provider contract with a dental plan in which many of my patients are enrolled. Can you offer some helpful tips on what I should or shouldn’t say to my patients regarding this shift?

A: The important thing to remember is that this may be the only plan option some of your patients have access to, whether it is offered by their employer, purchased from Covered California or purchased directly from the plan. With this in mind, it is important to be diplomatic and factual in the information you share. Offering negative comments about the dental plan is unprofessional and may make your patient feel uncomfortable or upset. Focusing on how this change positively impacts the patient and the treatment provided is key. Be sure to inform the patient as to what will or will not change in terms of courtesy billing the plan, assignment of benefits (if applicable) and the patient’s coverage and out-of-pocket treatment costs.

Q: I am unhappy with the reimbursement from a dental plan in which many of my patients are enrolled. What can I say to my patients?

A: Like the answer above, we recommend focusing on the care of the patient. Keep in mind that discussing plan reimbursement with your patient may be detrimental to the doctor-patient relationship, so we encourage you to be thoughtful and diplomatic in all discussions. If you are a participating provider with the patient’s dental plan, note that negative, fictionalized or disparaging comments may be in violation of your participating provider agreement.

Q: How do I respond when patients ask if I “take” their insurance when I’m out of network with their plan?

A: This is where semantics matter and honesty is the only option here as it is unethical to mislead patients otherwise. If you are not a contracted provider, explain to the patient that you are an out-of-network provider, but that you will work with the plan and will submit claims to the plan on the patient’s behalf. Additionally note that estimated charges will be presented for patient review prior to any treatment occurring.

Q: How do I explain to my patient that dental plans are not required to cover all treatments?

A:  Sharing the resource, Dental Benefits - What You Need to Know with your patients is one way to educate them on why their dental coverage is different from medical insurance in terms of coverage levels, annual maximums and more. Encourage your patient to review the plan documents from their employer (if it’s an employer-sponsored plan) or from the carrier (if it’s an individually purchased product) so they can become familiar with their benefits, coverage and limitations.

Q: Where can I direct patients who are unsatisfied with their current coverage?

A: First, suggest that the patient call their plan and inform them that they are unhappy with a service or policy. If the dental plan is unable to assist the patient, they may then turn to their employer’s HR representative to share dissatisfaction with the dental plan. Finally, you can refer the patient to the regulator of their dental plan, which may be the Department of Managed Care at 888-466-2219, or the California Department of Insurance at 800-927-4357. If the patient’s dental plan is self-funded, they can file a complaint with the U.S. Department of Labor at 866-444-3272.



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