FACT 1 – DENTAL INSURANCE IS A CONTRACT BETWEEN YOU, YOUR EMPLOYER AND THE INSURANCE COMPANY. We are not a party to that contract.
FACT 2 – DENTAL INSURANCE IS NOT MEANT TO COVER ALL FEES. It is meant to be an aid to your investment in your child’s dental healthcare. Many routine dental services are not covered by dental insurance.
FACT 3 – NO INSURANCE PAYS 100% OF ALL PROCEDURES. Many patients think that their insurance pays 90%-100% of all dental fees. 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.
FACT 4 – FREQUENCIES & LIMITATIONS OF BENEFITS. The frequency of payment for some procedures may be limited by an insurance company. This is most often encountered in a pediatric dental office with fluoride treatments. The American Dental Association and the American Academy of Pediatric Dentistry recommend the application of fluoride every 6 months or even at a higher frequency depending on the caries risk of the individual patient since it is proven to be highly effective against tooth decay. Our office follows those recommendations in order to achieve optimal oral health for your child. Therefore, if an insurance plan limits the frequency of the fluoride treatment, the parent will be responsible for this cost. This can also be encountered with other procedures, such as x-rays and sealants.
FACT 5 – 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”) 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 6 – 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.