Facts About Your Dental Insurance
According to the Centers for Disease Control and Prevention, about 27% of American adults have untreated cavities, while over 50% suffer from some level of gum disease. Unfortunately, many of these people fail to seek treatment, because of affordability issues.
Dental insurance can help offset the cost of dental care by paying for restorative treatments, along with preventative exams that catch minor problems in their infancies. To get the most from your benefits, however, it’s important for you to understand your policy.
What is Considered Basic Dental Care?
Most dental plans will offer 80% coverage for basic dental services, including fillings, non-routine x-rays, extractions, sealants and certain periodontal treatments. The typical plan will also cover the entire cost of preventive procedures, such as oral exams, routine cleanings, routine x-rays and sealants. On the other hand, some dental treatments, such as crowns, dentures and bridges, would not be considered basic dental care. In turn, the typical dental plan will only offer 50% coverage or less for these procedures.
If your insurance changes during the course of your treatment (for example orthodontics or dental implants) then your dental coverage may change.
OUR OFFICE POLICY REGARDING DENTAL INSURANCE
If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. By law your insurance company is required to pay each claim within 30 days of receipt. We file all insurance electronically, so your insurance company will receive each claim within days of the treatment.
PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We do our best to find your information and your coverage but sometimes your insurance company will limit the amount of information they give us. The best way to know if you are truly in network with our office is to personally call your insurance company and verify that we are in network.
We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not do with each claim. We also can not be responsible for any errors in filing your insurance. Once again, we file claims as a courtesy to you.
Fact 1 – NO INSURANCE PAYS 100% OF ALL PROCEDURES
Dental insurance is not like medical insurance. It is more like a coupon or a discount plan. Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage, or the type of contract your employer has set up with the insurance company. Unlike medical insurance, dental insurance has a maximum benefit per year. Once you reach that maximum benefit, all dental treatment will be out of pocket.
Fact 2 – BENEFITS ARE NOT DETERMINED BY OUR OFFICE
You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (“UCR”) used by the company. A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable, or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate. Insurance companies set their own schedules, and each company uses a different set of fees they consider allowable. These allowable fees may vary widely, because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR Fee. Frequently, this data can be three to five years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit. Unfortunately, insurance companies imply that your dentist is “overcharging”, rather than say that they are “underpaying”, or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.
Fact 3 – DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED
When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less.
MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment.