Your dental benefits are based on the agreement your employer negotiated with your insurance carrier. We encourage you to review the insurance benefit booklet provided by your employer to better understand the benefits they make available as part of your dental insurance coverage. The patient payment portion covered for procedures varies depending on the coverage provided by your employer. An estimate of the amount covered by your insurance company will be provided at the time of your treatment, based on the information they provide to us.
Some insurance companies will no tell dental offices the exact coverage and only give a range of coverage. Therefore, the estimate is never a guarantee of benefits or the amount that will be paid. We will file all insurance claims as a courtesy to our patients. This does not however, transfer the responsibility of your financial obligation to the insurance company. If the amount paid by the insurance company is less than or greater than the estimate, then you will be billed the difference or issued a credit on the account in the event of an over payment. Also, if an insurance company sends you a check please endorse the check and return it to our office. This is an annoying game some dental insurance companies by sending the insurance payment to the patient and not the doctor. You will not get paid to have dental work done.
Please let us know if you have questions about our financial policies or financing options prior to your treatment.
Dental Insurance is NOT real Insurance.
If you get dental insurance from your work or your spouse’s work and you pay nothing for the insurance then dental insurance is useful. Dental insurance if purchased as an individual is ALWAYS a losing bet. Dental insurance companies are like the casinos in Las Vegas: the house always win. For dental insurance companies, they have teams of lawyers that write huge policies. In these policies are a myriad of limitations, stipulations, provisions, exclusions, downgrades and tricks to limit the insurance companies paying out. The entire business model of insurance companies is to take in more money than they pay out. Therefore, the insurance companies make more profit when they deny coverage and benefits. The insurance companies have come up with lots of tricks to limit their losses. Below are frequent terms and tricks that dental insurance companies and employers use to reduce the amount of money they pay out.
Dental insurance is quite simply not insurance, in the true sense of the word. It’s not like home insurance or car insurance, where you pay a premium in exchange for blanket coverage in the event of losses or expenses. If dental insurance was truly insurance, patients would submit their claims for all necessary work that needed to be done and they would be fully reimbursed (minus an agreed-upon deductible).
If Dental Insurance worked like Car Insurance the insurance company would say:
“We will cover a new engine, but it will be downgraded to a four cylinder, and you will have to pay for the bumper out of pocket because we think it is cosmetic. That will max out what we pay for the year, so all other repairs will have to wait unless you also want to pay for it out of pocket.”
However, that’s not how dental plans work. What dental plans offer are benefits – a limited stipend to go towards funding dental care costs, which is a different thing. This stipend is useful and a valuable benefit to patients. Nevertheless, it is imperative that patients are not misled by the term “insurance” to the point where they have incorrect expectations. Because dental insurance does not exist.
The dental insurance companies chose this terminology and created this illusion that “In Network” providers are the best. This could not be further from the truth in my opinion. Dentist and Corporate Clinics that are In Network sign contracts with dental insurance companies to accept reimbursements that are 40 to 60 sixty percent less than the actual procedure cost. This lost revenue must be made up somewhere. In Network clinics hire the cheapest labor possible, use the lowest cost dental materials and choose the cheapest possible dental labs. Because the In Network providers are seeing patients at such a reduced fee the clinics must treat an extreme volume of patients daily. Patients are double and triple booked for doctors. Thus, patients often have to wait hours to be seen. The clinics overbook because they must treat as many patients in as possible. Furthermore, the most over treatment and inappropriate treatment our office sees come from In Network clinics. I feel these dental clinics are trying to make up the lost revenue by doing unnecessary treatment. Most offices that are In Network have a revolving door of dentist. This means that the dentist that you first saw and diagnosed problems might not be the same doctor that treats you. In Network dental offices have a very impersonal feel and they must do huge volumes of dentistry in order to recoup the lost revenue of agreeing to insurance companies contract rates. There is no long term trust and partnerships fostered by the patient and office because at In Network offices you are just a number / insurance policy. When patients leave the In Network Clinics for better dentistry, the In Network dental offices don’t care because they have signed up with so many insurance companies. The clinics have an endless stream of patients that are forced to go to In Network providers.
Out of Network:
The insurance companies seek to control every treatment decision and withholds the best treatment in favor of 2nd and 3rd tier options due to lower cost. Insurance Dictated Dentistry means the Insurance Companies do everything to control their losses (benefits paid out, what treatment is covered, fees and reimbursement levels) at the detriment of patients. It’s really very simple: Dental Insurances have profit margins and stock prices as their highest priority.
At my office, we refuse to let an Insurance Company dictate treatment. Our patients come first, and we will give them no less than our best judgment and care based on our experience and training. Therefore, we will continue to be out of network providers as this is the only way my office can provide the best care possible. The amazing ladies up front will still file insurance claims on your behalf.
Insurance carriers’ administrative decisions regarding how claims are processed vary greatly. To further confuse and make difficult for the patient and dental office is that the insurance companies don’t specifically address all procedures and guidelines in the policy or employee dental insurance handbook. For instance, Carrier X may allow a periodontal procedure every six month, while carrier Y might normally allow that same procedure once every two years. Carrier Z might have no frequency limit when it’s dentally necessary. It is vital to note that insurance carriers’ limitations, exclusions, and provisions are based on cost rather than dental necessity.
A “dental necessary” treatment is specified as such by the insurance claim administrator. Therefore when the dental insurance deems a procedure “Not Dental Necessary”, it is a stipulation of the insurance provider and does not mean that the dental procedure is not necessary. This is an indication of a restriction of a specific dental plan. This restriction can be due to an age limit for that procedure or a waiting period for that procedure. Also, the restriction can be due to a frequency limit. When coverage is insufficient on certain procedures, it is because that coverage was reduced to lower the cost of the employer’s insurance premiums.
Alternate Benefit Clause:
A common restriction to policies is the “alternate benefit clause.” This is a cost lowering feature that means, if there is a less expensive treatment or method that can produce the similar results, the plan will pay for the least expensive treatment. The dental insurance will not pay for the actual procedure performed or for the best treatment! For patients, this means a greater out-of-pocket cost, since the insurance carrier pays for a lesser procedure than what was actually performed.
Again, dental insurance is not really insurance. If during a hurricane a part of your house’s wall was knocked over. You home owners insurance would pay to replace the wall. If you home owners insurance was like dental insurance they would not pay for a new brick wall. However, they would pay for a wooden wall because the wooden wall would produce similar results. You would want the better, stronger and longer lasting brick wall. However, to save costs dental insurances will not always pay for the best treatment.
Most Extensive Procedure / Most Inclusive Procedure:
Carriers often have a rule that is referred to as “most extensive procedure / most inclusive procedure.” For a patient that means the dental insurance companies will only pay for the most extensive procedure performed. A crown is needed on a tooth when there large decay or parts of the tooth have broken. The dental crown returns the tooth to form, strength and function. Very often, Dr. Nugent will have to do a “build up”. This necessary build up procedure is vital to reshape the tooth properly in order to receive the crown. Therefore, insurance companies have exclusions that will not pay for the build up if performed on the same day as the crown. In order to pay for the build up the patient has to take time off of work/school, come to the office, get numb and have the build up performed. Then the patient has to come back again, get numb and have the crown procedure performed.
Dental insurance is not real insurance! Can you imagine health insurance acting like dental insurance? You break your leg. The orthopedic doctor fixes and sets the bone. However, you have to come back another day to get the cast in order for your health insurance to pay.
“Coordination of Benefits”
When a patient has coverage under two different policies, they often incorrectly thinks the entire bill should be covered by insurance. However, this is often not the case. “Coordination of benefits” (COB) is mandated when there is more than one carrier involved in the payment of claims.
If the insurance plan has a “Standard” COB, claims will be coordinated so that the totally payment will not be more than 100% of the actual charges. The double coverage provision is intended to prevent payments exceeding total expenses.
To lower the cost of insurance premiums most plans will have a “non-standard” COB. For example, the secondary carrier will only pay the difference of the amount it normally allows minus the amount the primary carrier paid. For instance, a primary carrier pays 70% of the cost of a filing, and a secondary carrier normally pays 80%. When the secondary receives the claim, it will only pay the 10% difference between what the primary paid and what its normal allowance is. Standard COB would have paid the remaining 30% of the claim amount.
Fee Charged vs. Fee Paid
“Usual, Customary, and Reasonable”
Insurance Premium costs are affected by the “ceiling amount” a carrier will pay per procedure. This amount is called the “usual, customary and reasonable” (UCR) fee. This allowable reimbursement amount is based on the zip code of the dental office. Each dental insurance company has its own “UCR” fee for zip codes. The insurance companies do not usually disclose these to dental offices, patients, or employers.
Typically, the insurance carrier and employer set the reimbursement level at a fee that varies between what 70%-90% of the dentists in that zip code charge. For a particular procedure that most dentists charge 550 for, some policies may base their claims payment amount at 600 or higher. However, when the employer wants to keep the cost of its policy down it has the option to buy a plan that reimburses at a lower level. In other words, instead of reimbursing at 550 or higher, it may only reimburse 500 of less for the procedure.
A COMMON MISCONCEPTION CAUSED BY THE TERM “UCR”
Let’s say that the dentist’s fee is 550 for that particular procedure (in this example, the amount most dentists charge). The patient’s employer purchased the lower cost policy that reimburses an amount of 500 or less. The carrier will state on the explanation of benefits (EOB) that the dentist’s fee is above the “usual, customary, and reasonable fee” fee. This might make the patient think his or her dentist’s fee is higher that most others. This is a common misconception. The reality is the employer chose a plan that does not reimburse at the level most dentists in the area charge. In these situations, the patient is accountable for additional “out-of-pocket” expenses. The employer reduced the ceiling amount (UCR) in the coverage in order to lower its overall insurance premiums.
It’s important to realize other employers with the same carrier (or even those with a different carrier) may consider 550 a “reasonable” fee.