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 and secondary (if applicable) dental insurance claims as a courtesy to our patients. It is essential that you provide current and accurate insurance information so that we may file your claim properly. Failure to do so can result in the claim being denied by insurance and you having to pay 100% of the treatment 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 our 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 their fee schedule to see what will be covered and at what percentage.
Important Dental Insurance Facts
Fact 1– No Insurance pays 100% of all procedures: Dental insurance is meant to be an aid to offset some of the cost of receiving dental care. Many consumers think that their dental insurance pays 100% of all dental fess and this is not true. Most plans pay approximately 50% to 80% of the average total fee, less your deductibles. Some pay more, some pay less. The coverage amount is determined by your insurance co.’s reimbursement fee schedule which is determined by the plan / coverage that has been negotiated between the employer and the insurance company.
Fact 2– Benefits are not determined by our office: You may notice that your dental insurer reimburses you a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the payment was reduced because your dentist’s fee exceeded the usual, customary and reasonable (UCR) fee used by the insurance company. A statement such as this gives the impression that any fee higher than their allowed fee is unusual, not customary or unreasonable for a certain service. This is misleading and inaccurate. Insurance companies set their own reimbursement “fee schedules” and each company uses different information to determine their reimbursement fee schedule. Insurers are VERY SLOW to update their reimbursement fee schedules to account for things like inflation, wage increases and medical/dental product price increases. Some insurers’ go years without adjusting their reimbursement fee schedules (i.e. their payout), however, they are VERY QUICK to adjust the insurance premiums that you pay to them for things like inflation, raw materials price increases, cost of living increases and CPI increases. As a result, the Insurance company has payout amounts based on old, outdated fee info but they are charging you insurance premiums that have been promptly increased for inflation, wage and materials price 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 todays materials costs, rent/overhead expenses, doctor’s pay and prevailing employee wages. In general, the 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 $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. Failure to do so can result in a denied claim and you having to pay 100% of the bill.
Fact 4 – Embedded Dental Policy and High Deductible policies; If you’ve chosen a high-deductible policy or if your dental policy deductible is embedded within your medical policy deductible, you will most likely have to pay significant out of pocket amounts ($2000, $3000, $5,000 or more) before your deductible is met and your dental coverage benefits even begin to kick in. These plans trick you with a low monthly premium payment but wind up being extremely expensive!! You are responsible for knowing if you have a high deductible or embedded policy, not our office.