Mrs. B was referred to me for a periodontal consultation. When my examination confirmed her dentist’s diagnosis of chronic generalized periodontitis, I explained the situation and outlined her treatment options. "Just take care of me," she said when I raised the subject of cost. "We have dental insurance where I work, so the price really doesn’t matter."

Ah, if only that were true. The public assumes that dental insurance is more or less like medical insurance, promising what, for most of us, is virtually unlimited care for a very modest deductible or copayment at the time of service. In reality, of course, the two kinds of coverage could hardly be more different. And it usually falls to the dentist to break the news to the patient.

I’m no actuary, but it seems to me that all plans can all be placed somewhere along a continuum according to the gravity of the peril against which one is being insured. At one end of the spectrum are the really bad things we insure against—death, fire, flood—but for which we hope we’ll never have to file a claim. At the other extreme are medical savings accounts, which are essentially tax-advantaged budgeting tools. Everything else falls somewhere in between. On my conceptual A–Z scale, with savings accounts at A and life insurance at Z, medical insurance might be found somewhere around M, auto insurance closer to H, and dental insurance well up toward D. People buy dental coverage primarily to pay for the routine rather than to mitigate the catastrophic, and to a considerable extent they control how and when they incur claims. If someone starts talking about "maxing out" a life insurance policy by the end of the year, a psychiatric intervention is in order. Yet this very same calculation is perfectly sane and sensible when applied to dental insurance.

Getting back to Mrs. B, we scheduled her for two surgical visits and contacted her insurance carrier for preauthorization, which was granted. The periodontal procedures and healing were uneventful, and the patient and I were both satisfied with the results. But then things turned ugly. Her insurance claim was turned down flat. We were informed that the procedure was "not medically necessary," based on a review by ... whom? Some unidentifiable person, with unspecified training, applying undocumented guidelines using form letters had this responsibility. The insurance carrier really meant to say that the service was not covered rather than unnecessary. Along the way, the patient came to suspect that the work really was unnecessary, and that my treatment plan was motivated by the prospect of a fat fee from her insurance company.

Now, it is clear that no unsubsidized insurance program can survive for long unless it brings in more than it pays out. It’s a simple equation: profit equals premiums, plus investment earnings, minus claims, minus costs. Trading off these four components, while staying simultaneously profitable and competitive, is an arcane business. For the dental profession, direct reimbursement may be a good option to consider.

Rather more common is the case of the convoluted coverage, where the reimbursements are real, but not what the patient might reasonably expect. My personal favorite was a patient who thought he had coverage for crown and bridge services. He did, but it covered just 50 percent of the fee for recementation of existing crowns and bridges ... once every two years. Can you really blame this patient for being angry when he learned that his new crown would be at his own expense? Unfortunately, it’s the dentist and the staff who bear the brunt of this anger, not the company that wrote the policy or the employer who selected it.

And here we have the root of the problem. Nowadays most employees value and expect "dental coverage," even if they’re a little vague about just what that means. But since dental insurance is toward the "A" end of the insurance spectrum, there’s not a lot of economic wiggle room: if the policy has a $500 annual limit with broad coverage, the premiums simply can’t be much less than $500. So employers, eager to attract good employees, cast around for ways to offer this popular benefit at an affordable cost. The best of the plans are straightforward, consistent and fair; the worst are little better than shams, and are probably less than worthless in building employee loyalty.

Although the bad guys provide us dentists with the lion’s share of our aggravation, the fact is that most insurance carriers and health maintenance organizations are basically good guys, even when I don’t like their restrictions or can’t live with their fee schedules. At least I can look the patient in the eye and explain the situation, discuss alternatives, and work out a treatment plan and payment schedule with which we may not be totally happy, but on which at least we can both count.

And at the top echelon, there are some really good guys out there. Companies that have recognized that satisfied customers are not inconsistent with profitability. Companies sponsoring serious research, creating innovative programs for dental health, taking the long view that the best way to reduce claims is by reducing disease. Companies seeking to understand how dental health affects general health, and using that knowledge to benefit their policyholders and shareholders alike.

As is so often the case, education is going to be key to reducing the miscommunication and strife that sometimes surrounds dental insurance, and reimbursement. Individual dentists should explain to their patients as clearly as possible how their plan works, and why. An alternative is to stress to the patient that they need to check out their coverage as individuals. There’s no reason why dental care can’t be a genuine benefit rather than a bone of contention.