Dental Insurance

Dental insurance benefits are considered a method of reimbursing the patient for fees paid to the doctor and are not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. The payment of fees for treatment incurred is the obligation of the patient, whether or not the insurance company ultimately reimburses you, the patient.

Your dental insurance is a contract between you and/or your employer and/or the insurance company.  Your dental insurance plan may be a form of compensation provided by your employer. You can expect the carrier (insurance company) to reimburse you for a portion of the treatment fee. That portion is determined by the contract between you and/or your employer and the insurance company. The amount your plan pays is determined by how much was paid for the plan. The higher the premium paid by you and/or your employer, the more generous the reimbursement benefit.  The less paid in premiums for the insurance, the less you will receive in benefits.  Remember, you get back only the premiums paid into the plans less approximately 30% in insurance company “administrative costs.”  

Although we are not a party to the contractual arrangement with your insurance company, we will assist you in receiving the maximum reimbursement to which you are entitled. As a convenience to you, we will process your insurance claims in order for you to receive this maximum benefit.  We will also gladly provide the necessary documentation should your insurance company have any questions about the treatment provided.  Questions regarding why your company includes or excludes certain procedures should be directed to your dental insurance company and/or employer.

You can be confident that we will always provide you with our best services without regard to the limitations imposed by your dental insurance benefits. To do otherwise would violate our dedication and commitment to you, our number one priority.  The insurance companies’ goal is to make money, period.  Their desire is to minimize payments and to have you wait an extraordinary amount of time for reimbursement so that they can use “your” money.  The quality of care you receive is not a priority for them.

Our fees are based on your individual treatment needs.  A cost estimation of our professional treatment and procedures necessary for the improvement of your dental and general health will be provided. The exact amount of reimbursement will vary between insurance companies. Some companies reimburse based on an arbitrary “schedule” of fees, which has no relationship to the current standard, or the cost of your care. We can submit your individualized treatment plan for a pre-estimate of benefits.  Please be aware that a pre-treatment estimate is not a guarantee of payment, and the patient is responsible for all charges incurred.

Further, most dental insurance policies are limited and often only pay for a portion of the procedure(s) that may need to be done.  The majority of dental insurance plans reimburse a patient for approximately 30%-80% of treatment costs.  At our office, your payment is due in full at the time of service.  Then, the portion covered by insurance is set up to be delivered directly to you.  If the insurance refund gets mailed to our office in error, we will send you the refund check in the mail unless you instruct us otherwise.

Medicare

The Medicare program does not cover most routine dental services.

The Medicare law clearly excludes coverage “for services in connection with the care, treatment, filling, removal or replacement of teeth or structures directly supporting teeth.”  Dental procedures (including root planing, periodontal surgery and dental implants) are not covered benefits by Medicare. Our office does not participate in Medicare and no Medicare claim will be filed for any treatment provided by our office. You are responsible for all charges and may pay for them personally or through any other insurance you may have.

Dental Insurance Frequently Asked Questions

Understanding your dental benefits is not easy and there is a great deal of confusion about dental insurance.  Please remember that we do not work for any insurance company, but WE WORK FOR YOU, THE PATIENT. Our treatment recommendations are based solely on what will give you the best periodontal treatment and outcome. Insurance companies' treatment recommendations are based solely on what is best for their profit margins. 

It is important to know that each contract will specify what types of procedures are considered for benefits.  Even if a procedure is medically and dentally necessary, it may be excluded from your insurance contract.  This does not mean that you do not need the procedure.  It simply means that your plan will not consider the procedure for payment.  For example, cosmetic procedures and implants are often excluded from a dental plan.

It is a mistake to let benefits be your sole consideration when you determine what you want to do about your dental condition. Dental insurance is not and has never been designed to be a “PAY-FOR-ALL.”  Remember, whether your plan covers a major portion of your dental bill or only a small amount, dental benefits are good for patients because they help pay for needed treatment.  It is only meant to be an aid. This section is provided to answer a few common patient questions:

Why doesn’t my insurance cover all the costs for my dental treatment?

Dental insurance is not really insurance (a payment to cover the cost of a loss) at all.  It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment.  The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month.  Most benefit plans are only designed to cover a portion of the total cost.

But my plan says that my exams and certain other procedures are covered 100%.

That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge.  For example, say your dentist charges $80 for an examination (not counting x-rays).  Your carrier may allow $60 as the 100% payment for that examination, leaving $20 for you to pay.  Many plans tell their insured that they will be covered “up to 80%” or “up to 100%,” but do not clearly specify plan fee schedule allowances, annual maximums or limitations.  We have found that most plans cover about 35% to 65% of major services based on the plan’s pre-established maximum fee allowance, which varies from carrier to carrier.

If my plan does not really cover any procedures at 100%, why does it say it will?

Benefit plan booklets are often difficult to understand.  If any part of your plan is not clear to you or if you think something is wrong concerning what your plan covers, you should contact your Employee Benefits Coordinator or the Human Resource department where you work, or your insurance company.   

How does my insurance carrier come up with its allowed payments?

Many carriers refer to their allowed payments as UCR, which stands for usual, customary and reasonable.  However, usual, customary and reasonable does not mean exactly what it seems to mean.  UCR is actually a listing of payments for all covered procedures negotiated by your employer and the insurance company.  This listing is related to the cost of the premiums and where you are located in your city and state.  Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire.  UCR payments could be more accurately described as negotiated payments.  In our view “usual and customary” is an insurance term that means, “average care.”  The care we provide is designed to be excellent rather than average.  

Since the payments are negotiated, does this mean that there is always a balance left for me to pay?

Typically there is always a portion that is not covered by your benefit plan.

If I always have a balance to pay, what good is my insurance?

Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something.  Any amount covered reduces what you have to pay out of pocket.  It helps!

I received an Explanation of Benefits from my insurance carrier that says my dental bill exceeded the usual and customary.  Does this mean that my dentist is charging more than he/she should?

You may receive an explanation of dental benefits (EOB) from your insurance company stating that dental fees are higher than the usual and customary dental fees.  An insurance company surveys a geographic area, finds the average, then takes 90% of that fee and considers it the customary fee.  Additionally, insurance companies only perform this survey once every 5-7 years, as it is a costly exercise for them.  The coverage does not keep up with the costs that quality dentistry faces today.  Remember that what insurance carriers call usual and customary is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment.  It is frequently much less than what any dentist in your area might actually charge for a dental procedure, but it does not mean that your dentist is charging too much. 

Why is there an annual maximum on my benefits?

Maximums limit what a carrier has to cover each year.  Amazingly, despite the fact that costs have steadily increased, annual maximum levels of $1000 to $2000 for dental care have not changed since the 1960s.

Why do some benefit plans require me to select a dentist from their list?

Usually the dentists on the list have agreed to a contract with the insurance benefit plan for a specified reduced payment for treatment.  These contracts have restrictions and requirements.  If you choose a dentist from their list, you typically will pay less toward your dental care than if you choose a dentist not on the list.  If your dentist is not on your insurance company’s list, this does not mean that something is wrong with the dentist or the office.

Why does my benefit plan only pay toward the least expensive alternative treatment?

To save money, many dental plans allow a benefit only for the least expensive method of treatment.  For example, your dentist may recommend a crown, but your insurance plan might only cover the cost of a filling.  This does not mean that you have to accept the filling.  The good news is that you may choose the alternate procedure and some benefit will still be paid; the bad news is that more of the fee will be your responsibility.  Remember that your dentist’s responsibility is to prescribe what is best for you.  The insurance carrier’s responsibility is to control payments and ensure their profits.

Why won’t my insurance pay anything toward some procedures, such as x-rays, cleanings and gum treatments?

Your plan contract might set an annual limit on the number of times it will cover specific procedures, such as x-rays, cleanings and gum treatments, because these are the types of treatment that many people need to have frequently.

I know that my insurance plan doesn’t go into effect until next month.  Why can’t my dentist do my treatment today, but send in the claim next month so that the insurance will pay?

State laws regulate these issues.  It is insurance fraud to change the dates of service on a claim.  Both the patient and the dentist can be prosecuted.

Why doesn’t my dentist participate in my dental benefits network plan?

Some plans require that the network dentists observe restrictions to treatment.  Many dentists are not comfortable with this because the restrictions may prevent the dentist from performing the best care that you deserve.

What should I do if my insurance doesn’t pay for treatment that I think should be covered?

Because your insurance coverage is between you, your employer and the insurance carrier, your dentist does not have the power to make your plan pay.  Regardless of your dental insurance benefits, you are responsible for the total cost of treatment. However, the Employee Benefits Coordinator at your place of business may be able to help.  Consumers (patients) may also lodge complaints with the State Insurance Commission.

Please remember that as dental care providers, our relationship is with YOU, not the insurance company.  Further, most dental insurance policies are limited and often only pay for a portion of the procedure(s) that may need to be done to improve your dental and general health.  We do not recommend nor render our services on the basis that insurance companies will accept or pay all our fees.  Each fee is specific for your individual treatment needs.  While the filing of insurance claims is a courtesy that we extend to our patients, all treatment fees are your responsibility from the date the services are rendered.  If questions arise, we encourage you to contact your dental insurance company and our office promptly for assistance in the management of your account.

*All questions and answers provided by Stepping Stones to Success.