Host: Eon Engelbrecht (E-Radio-SA) | Guest: Dr Clifford Yudelman (OptiSmile, Sea Point, Cape Town) Ever opened a dental bill and wondered why your medical aid covered so little of the work that actually matters? In this episode, Dr Clifford Yudelman pulls back the curtain on the frustrating gap between what schemes pay for and what genuinely protects your teeth. From risk versus savings, to PMBs, gap cover and pre-authorisation, it is a frank and refreshingly honest conversation about keeping your smile healthy without letting your finances take the hit. Whether you are in South Africa or listening from abroad, you will come away knowing the right questions to ask and how to put the control back in your own hands. Episode Questions and Answers [1:12] Why does medical aid often not cover the treatments that actually save your teeth best, such as root canals or crowns? Most schemes were built years ago around a medical and hospital model, not around preventive or restorative dentistry. Dental benefits cluster around cheap, short-term work such as cleanings, basic fillings and extractions, while root canals and crowns are treated as expensive even though they preserve teeth and prevent far bigger costs down the line. Schemes prioritise immediate cost containment over lifetime value, so patients end up funding the most tooth-saving treatments themselves. South Africa compounds this with hundreds of billing codes that make bills hard to understand and claims hard to win. [4:49] What is the difference between risk, benefits and savings when it comes to dentistry? Risk benefits cover unpredictable, high-cost events such as hospitalisation or trauma, with the cost spread across everyone the scheme insures. Your savings account is your own money set aside for day-to-day care, and most routine dentistry comes out of there. The crucial distinction: a savings account is not insurance. It does not spread risk, it simply manages your cash flow, and once it is depleted you pay out of pocket. Schemes also rely on the fact that many people never use their full dental savings. [7:07] Is it not better to self-insure by saving cash than to upgrade to a high-tier medical aid? For dentistry, generally yes. High-tier plans cost considerably more each month for only limited extra dental benefit, and you are paying for the whole family when often only one member needs treatment. Health economics supports self-insuring predictable costs, provided you still carry proper cover for catastrophic events. The ideal is a balance: strong hospital and emergency cover, plus disciplined personal savings for the family's dentistry, which puts control back in your hands. [8:27] What are PMBs (prescribed minimum benefits), and do they actually apply to dentistry? PMBs are conditions schemes are legally required to cover in South Africa regardless of your plan, but in dentistry they are extremely limited. They usually apply only to acute emergencies, such as an infection threatening your general health, not routine or preventive care. Even when a dental condition qualifies, the scheme may fund only the cheapest option, which is often an extraction rather than tooth-saving treatment. Clifford's example: a neglected infected molar that lands you in hospital will get life-saving antibiotics and a limited extraction covered, but not a properly done root canal or surgery under sedation. [10:18] Why do dentists charge above medical aid rates? Scheme tariffs are often far below the real cost of modern, high-quality care and have not kept pace with advances in materials, technology, infection control and expertise. Charging strictly at those rates would make many practices unviable or force quality down. Clifford walks through a single small filling at OptiSmile: painless numbing with a disposable wand, premium local anaesthetic, the best filling material, a full hour booked and a free follow-up bite check, plus an air-abrasion cleaning machine that cost R100,000 and powder at roughly R4,000 for four tubs that do not last long. At scheme rates the reimbursement would not even cover materials, let alone rent. It is about sustainability and current clinical standards, not profiteering. [13:06] How can patients get gap cover to help with dental surgery costs? Gap cover is primarily designed for in-hospital procedures, and dental benefit varies widely, with many policies excluding dentistry altogether, so always read the small print. It can help reduce out-of-pocket costs for something like impacted wisdom teeth removed under general anaesthetic. It is not a substitute for dental savings, just a supplementary tool for specific scenarios. As with all insurance, the odds favour the provider: across a family you might only have a few sets of wisdom teeth over a lifetime while paying premiums for years. The house always wins. [14:27] Does medical aid ever cover implants or cosmetic work? In most cases no, or the amount covered is so low it barely helps, which leaves patients thinking the dentist is overcharging. Clifford breaks down a roughly R20,000 implant: the dentist's fee is only a portion (around R7,000), with the rest going to the high-quality implant components, the surgical guide, the 3D X-ray and the lab work that ensure it is placed properly and lasts. A scheme might pay R2,000 if you are lucky. The gap is not the dentist's pricing; it is that schemes exist to make money, not to make you happy. [15:49] How should patients read a dental quote and check it against their scheme rules? Look for the procedure codes, the descriptions and the sequencing of treatment, which lets you compare against your scheme benefits and spot exclusions, though scheme documents are often 40 to 50 page PDFs. A practical modern shortcut is to paste both your quote and your policy into an AI tool such as ChatGPT, Gemini or Claude and ask it to flag the likely pitfalls. Contracted-in practices can also submit a pre-authorisation, but an approval is never a cast-iron guarantee that the scheme will not later find a reason to pay less. [18:05] What is pre-authorisation, and why is it critical to get it in writing? Pre-authorisation is the scheme confirming in advance what it will cover, but verbal approval is unreliable, so always get written confirmation by email. Even with it, schemes often reimburse only at their own tariff, which may be a fraction of the real fee, so confirm the actual rand amount up front. Documentation is a form of financial self-defence if a dispute arises later, and AI now makes drafting those emails quick and clear. [20:07] How can OptiSmile help patients submit claims, even as a private practice? Even though OptiSmile does not bill medical aid directly, it provides detailed invoices with the correct medical aid codes and supporting documentation so patients can claim themselves, and using the proper codes may even be a legal requirement. For patients with comprehensive overseas insurance, which tends to pay well but demands extensive documentation, the practice will compile a full record of diagnoses, treatment and codes, with AI assistance. What it will not do is phone your scheme and fight the claim on your behalf. The aim is informed choice and clinical independence, not dependency on a system that may not serve your long-term oral health. Outro And that wraps up another honest, no-nonsense chat. Eon thanks Dr Yudelman for cutting through the jargon and reminding us that informed patients really do make better long-term decisions, for their teeth and their wallets alike. The takeaway is a simple one: know where you are headed, understand your risks, and be clear on who is paying for what before any treatment begins. Next week the conversation turns to the fun side of dentistry, with a look at the dental facelift, otherwise known as anti-ageing dentistry. It is one you will not want to miss. Further Resources All links below are verified OptiSmile pages. Dental implants at OptiSmile: https://optismile.co.za/dental-solutions/dental-implants/Cosmetic dentistry at OptiSmile: https://optismile.co.za/dental-solutions/cosmetic-dentistry/Full range of dental solutions: https://optismile.co.za/dental-solutions/OptiSmile home and online booking: https://optismile.co.za/ Disclaimer: The content provided in this podcast, "Save Your Money Save Your Teeth" on Medical Mondays, is for informational and educational purposes only. It is not intended to serve as dental or medical advice. The insights and opinions expressed by Dr. Clifford Yudelman and any guests are designed to foster a better understanding of dental health, preventive measures, and general well-being, but should not be interpreted as professional dental or medical recommendations. Dr. Clifford Yudelman does not diagnose, treat, or offer prevention strategies for any health conditions directly through this podcast. This platform is not a substitute for the personalized care and advice provided by a licensed dental or healthcare professional. We strongly encourage our listeners to consult with their own dental care providers to address individual dental health needs and concerns. The information shared here aims to empower listeners with knowledge about dental health but must not be used as a basis for making health-related decisions without professional guidance. Your dental care provider is the best source of advice about your dental and overall health. Please always seek the advice of your dentist or other qualified health professionals regarding any questions or concerns about your dental health.
