When patients receive a dental bill, they often assume their insurance will cover a fair portion of the cost. However, dental insurance companies have mastered the art of using misleading language to make it seem like they are providing reasonable reimbursements—when in reality, they are limiting their payouts and protecting their bottom line. Understanding the terms they use can help patients see how these companies prioritize profits over patient care.

Decoding the Terminology

Insurance companies use specific terms to describe how they determine reimbursement rates, but these terms are often crafted to shift blame to the dentist while concealing how insurers are actually reducing what they pay. Let’s break down some of the most common ones:

1. UCR (Usual, Customary, and Reasonable)

This term makes it sound like the insurance company is basing its payments on the average fee in a given area. However, insurers set their own UCR rates—often much lower than the actual market rates. This allows them to cap payments and make it seem like a dentist is charging “too much,” when in reality, the insurer is just paying too little.

2. MAC (Maximum Allowable Charge)

The insurance company sets a cap on what they are willing to reimburse for a procedure, regardless of what the dentist actually charges. While this sounds like a logical cost-control measure, it’s an arbitrary limit that often forces patients to cover the difference.

3. PPO Fee Schedule & Contracted Fees

When dentists become in-network providers under a PPO plan, they agree to significantly reduced fees in exchange for being listed as “preferred providers.” Insurance companies promote these discounts as a benefit to patients, but what they don’t disclose is that the primary beneficiary is the insurance company itself. By reimbursing dentists at lower rates—often just 45% to 60% of their standard office fees—insurance companies maximize their profits while continuing to collect high premiums.

To compensate for these drastic fee reductions, many in-network dentists are forced to make compromises. This can mean shorter appointment times, less thorough diagnostics, reduced communication, and lower-quality materials for restorations. Ultimately, these limitations affect the longevity and effectiveness of dental work.

A filling that lasts only three years due to lower-quality materials and rushed placement is far more costly in the long run than one that lasts 7-10 years when crafted with superior materials and techniques. Similarly, crowns, dentures, and implants made with substandard technology wear down more quickly, leading to frequent replacements and higher costs for the patient over time.

Choosing a dentist who prioritizes quality over insurance-imposed limitations ensures better oral health, longer-lasting restorations, and, ultimately, greater value for the patient. Investing in high-quality care today means fewer replacements, fewer complications, and better long-term results.

4. R&C (Reasonable and Customary)

Similar to UCR, this term suggests that the insurer is paying a fair market rate. However, these limits are often set below the actual cost of treatment, leaving patients with unexpected out-of-pocket expenses. Again, insurers shift the blame to the dentist rather than acknowledging that their payment standards are outdated and arbitrary. Some even slander the dentist on EOBs stating the dentist overcharges, charges above ‘reasonable customary’ fees which are only arbitrarily set by the dental insurance company. They will recommend the patient find another dentist in-network. This language is meant to grow the base of in network dentists willing to compromise care to increase patient load.

5. Table of Allowances

Under this model, the insurance company pays a fixed amount for each procedure—usually far less than what the procedure actually costs. Patients believe they are receiving coverage, but in reality, they are left to pay a large portion of the bill themselves. Insurers use this strategy to claim they are “helping” while keeping their payouts low.

6. Capitation Fees

Under Dental HMO (DHMO) plans, insurance companies pay dentists a fixed amount per patient per month, regardless of how many services that patient actually receives. This makes it seem like patients are getting affordable or “free” care, but in practice, it often discourages dentists from providing comprehensive treatment since they are not adequately compensated for each procedure. The insurer benefits by keeping payouts low, all while continuing to collect premiums.

The Real Impact on Patients

The common theme among all these terms is that insurance companies have structured their fee schedules to protect their own profits while shifting costs onto patients. They make it seem like they are offering generous coverage when, in reality, they are setting limits that restrict what they actually pay. Meanwhile, they subtly suggest that dentists are to blame for the remaining balance, when the real issue is the insurance company’s own payment structure.

What Can Patients Do?

• Ask your dentist for a cost breakdown before treatment to understand what your insurance is estimated to cover. They will likely have a convenient monthly payment plan to help you utilize the gift of benefits your employer has given you while receiving high quality dental care that will save you money in the long run.
• Ask your employer for a Health Savings Account. You will save the taxes on the money you put away over the year. If the maximum a family is allowed to contribute to an HSA is $8,300 you could save $2,000 or more on taxes that could be used toward your dental care.
• Replace your self purchased dental plan with an ‘in-house membership plan’ offered by many dental offices, which often provide better value than traditional insurance. Two adult cleanings with x-rays per year are about $660. If you are spending an equivalent or higher amount on insurance premiums it would benefit you to discuss your options with your dentist.

At the end of the day, dental insurance should be about patient care—not protecting corporate profits. By understanding these terms and asking the right questions, patients can make informed decisions about their dental health and financial well-being.