Our office is out of network with all insurance companies so we have no contract or agreement with your insurance company but you as the policyholder 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.
Because we are out of their networks, the insurance companies will not share their reimbursement fee schedules with us but they must share them with you when requested. Our treatment plans are based on your child’s dental needs to achieve the best overall outcome. The parent/responsible party is ultimately responsible for payment of all treatment costs not covered by or denied by insurance. For larger treatment plans and those requiring General Anesthesia we can submit a pre-determination to your insurer to see what procedures they will cover and at what percentage before beginning treatment. A Pre-D takes 2-4 weeks for an insurer to complete and return to our office.
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 between 50% to 80% of the average total fee, less your per patient deductibles. Some pay less, very few pay more. The coverage amount is determined by your insurance co.’s reimbursement fee schedule which is determined by the plan that has been negotiated between the employer and the insurance company. Lower cost insurance plans pay less in coverage.
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 materials 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 you pay them to factor in inflation, raw materials price increases, cost of living and CPI increases. As a result, the Insurance company has claim payout amounts based on old, outdated fee info but they are charging you insurance premiums that have been promptly increased. Through their wording, insurance companies imply that your dentist’s fees are unusual, not customary or unreasonable rather than disclosing they are actually under-reimbursing for dental care by not factoring in current dental product prices, overhead and prevailing staff wages. In general, the less expensive insurance policies have lower reimbursement 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 your dental policy is embedded within your medical policy or you’ve chosen a high-deductible policy you will most likely have to pay significant out of pocket amounts ($2000, $3000, $5,000 or more) to meet your medical deductible BEFORE your dental coverage benefits kick in. These plans trick you with a low monthly premium payment but wind up being extremely expensive when treatment is needed. As the insurance holder, you are responsible for knowing if you have a high deductible or embedded policy, not our office.