We file primary dental insurance claims as a courtesy to our patients. If you should have a secondary insurance, we will provide you with the necessary information for you to file to your secondary carrier. It is essential that you provide us with accurate information in order to file your claim properly.
Please understand that our office is not an In-Network provider so we do not have a contract with your insurance company but you do. We are not responsible for how your insurance company processes its claims nor do we know exactly what your insurance company will or will not pay on a claim. Our office bases treatment on your child’s dental needs and not what your insurance will pay. Our pediatric dentists are providing professional services to your child, not to your dental insurance company. Consequently, you are ultimately responsible for payment of services rendered.
Facts Concerning Dental Insurance
Fact 1– No Insurance pays 100% of all procedures: Dental insurance is meant to be an aid in receiving dental care. Many consumers think that their dental insurance pays 90% to 100% of all dental fess. This is not true! Most plans only pay approximately 50% to 80% of the average total fee. Some pay more, some pay less. The percentage is determined by how much you or your employer has paid for the dental coverage AND the type of contract your employer has negotiated with the insurance company.
Fact 2– Benefits are not determined by our office: You may have noticed that sometimes your dental insurer reimburses you at a lower rate than the dentists actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentists fee has exceeded the usual customary, or reasonable fee (UCR) used by the insurance company. A statement such as this gives the impression that any fee greater than the amount reimbursed by the insurance company is well above what most dentists in the area charge for a certain service. This is very misleading and is simply not accurate. Insurance companies set their own fee schedule and each company uses a different set of fees that they deem allowable. These allowable fees may vary widely because each company collects their own fee information. Insurance companies are very slow to update the treatment fee information they collect, but very prompt in adjusting the premiums you pay, and frequently their fee data can be 3 to 5 years old. The insurance company takes this data and arbitrarily sets their allowable UCR fee. As a result, the Insurance company is setting reimbursement rates based on older fee info. Unfortunately, through their wording, insurance companies imply that your dentist is overcharging rather than explaining that they are under-reimbursing for procedures. 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 understanding dental benefits, deductibles and co-payment 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, you can calculate the benefit that you will be reimbursed. First a deductible (if applicable), on average $50.00, will be subtracted, leaving a $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of the $100.00, or pays $80.00. Of, course, if the UCR is less than $150.00 or your plan maybe only pays 50%, then your insurance reimbursement will be significantly lower. Most importantly, please keep our office informed of any insurance changes such as policy name, insurance company address or change of employment.