Our office is out of network with all insurance companies so we have no contract or agreement with your insurance company but you do. We file primary dental insurance claims as a courtesy to our patients. If you have secondary insurance, we can provide you with the necessary forms for you to file with your secondary carrier. It is essential that you update us with timely and accurate insurance information so that we may file your claim properly. Failure to do so can result in the claim filing window after treatment date expiring and you having to pay 100% of the cost.
We are not responsible for how your insurance company processes claims nor do we know exactly what your insurance company will or will not pay on a claim. Our treatment plans are based on your child’s dental needs and not on 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 all services rendered. We can always provide you with a treatment plan and dental procedure codes so you can contact your insurer for coverage details.
Important Dental Insurance Facts
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, less your deductibles. Some pay more, some pay less. The coverage percentage is determined by how much you or your employer pay for the dental plan 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 your dental insurer reimburses you based on a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the payment was reduced because your dentist’s fee has exceeded the usual, customary and reasonable fee (UCR) used by the insurance company. A statement such as this is misleading and gives the impression that any fee higher than their payment is unusual, not customary or unreasonable for a certain service. This is very misleading and inaccurate. Insurance companies set their own reimbursement fee schedules and each company uses different information to determine their UCR reimbursment amounts. Insurers are VERY SLOW to update their UCR fee schedule to account for things like inflation, cost of living increases and medical/dental product price increases. However, they are VERY QUICK to adjust the insurance premiums that you pay to them for things like inflation, CPI, and cost of living increases. As a result, the Insurance company has UCR amounts based on older, outdated fee info but they charge you premiums that have been promptly increased for inflation and other living expense increases. Through their wording, insurance companies imply that your dentist’s fees are unusual or unreasonable rather than disclosing they are actually under-reimbursing for procedures. In general, less expensive insurance policies use lower reimbursement UCR fee schedules.
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 a procedure is $150.00. Assuming that the insurance company allows $150.00 as its 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. Now, if the UCR is $100 for that same $150 procedure and your plan pays 80% and your deductible has not been paid then your insurance reimbursement will be $30 leaving you to pay $120. If the deductible had already been met, the insurance reimbursement would be 80% of $100 or $80 leaving you to pay the $70 difference. Unfortunately, insurance companies are experts at reducing the amounts they pay out in claim benefits. Most importantly, please keep our office informed of any insurance changes such as insurance company name or address change, employer changes, Member ID or Group number changes.
Fact 4 – If you’ve chosen a high-deductible policy or if your dental deductible is embedded in your medical policy deductible, you may have to pay significant out of pocket amounts ($1000, $2000, $3000 or more) before your deductible is met and dental insurance benefits start to kick in. You are responsible for knowing if you have a high deductible policy, not our office.