Dental Insurance: Points to Consider

The following is a plain-language synopsis of most dental insurance contracts. Please read it carefully, and perhaps keep it for future reference.

  • Dental insurance benefits do not work in the same way as medical insurance. There is almost always a co-payment due from the patient for almost every procedure. There are "deductibles" in all plans. At one time these deductibles were never taken out of preventive treatment ("cleanings"). Recently many carriers have begun to take deductibles out of preventive treatment.
  • Irrespective of any dental insurance benefits that might exist, the patient is always legally responsible for the entire cost of dental treatment.
  • The extent of dental coverage is solely dependent on the dental insurance plan purchased by the employer. The higher the premium the employer pays, the greater the dental insurance benefits.
  • Even if there is a written predetermination of benefits returned from the insurance carrier, it is possible that after treatment is provided, there are no insurance benefits payable.
  • We (the dental office) have absolutely no power or leverage to deal with the insurance carrier. Only the employee or the contract purchaser has power. Any complaints about benefits, payment, or coverage should be directed to Human Resources or the company owner.
  • The letters UCR on insurance vouchers stand for Usual, Customary, and Reasonable fee. The dollar amount you see as UCR has no basis in reality. It is an arbitrary amount determined solely by the plan selected and insurance premium paid by the employee. There is no relationship to the actual dental office fee. The better the plan (i.e., the more premium paid), the higher the UCR will be.
  • There is no universal coverage and payment schedule established. Just because an insurance code describing a dental service exists, it does not guarantee that it will be a paid benefit under your policy. There are many dental procedures that are necessary, and many of them are preventive, but are not covered benefits.
  • Financial benefits cannot be saved and carried over into the next year.

Your dental benefits almost always have a yearly maximum contribution level. This amount is the MOST your insurance carrier is contractually obligated to pay during a defined year (calendar or otherwise). When this amount is reached, there will be no further dental benefits payable until the next benefit year. If you have already begun some additional dental treatment prior to the maximum being reached, the insurance carrier has no payment obligation beyond that of the annual maximum.

The Facts about Dental Insurance

As an optimal care dental practice, we strongly believe our patients deserve the best possible dental services we can provide. In an effort to maintain a high quality of care, we would like to share some facts about dental insurance with you.

  • Fact #1: Your dental insurance is based upon a contract between your employer and the insurance company. Should questions arise regarding your dental benefits, it is best for you to contact your employer or insurance company directly.
  • Fact #2: Dental insurance benefits differ greatly from general health insurance benefits. In 1971, your dental insurance benefits were approximately $1,000 per year. Figuring a 6% rate of inflation per year, you should be receiving $4,549 per year in dental benefits. Your premiums have increased, but your benefits have not. Therefore, dental insurance is never a pay all; it is only an aid.
  • Fact #3: You may receive a notification from your insurance company, stating that dental fees are "higher than usual and customary." An insurance company surveys a geographic area, calculates an average fee, takes 80% of that fee and considers it customary. Included in this survey are discount dental clinics and managed care facilities, which bring down the average. The fee for service doctor in private practice will have fees that insurance companies define as higher than "usual and customary."
  • Fact #4: Many plans tell their participants that they will be covered "up to 80% or up to 100%," but do not clearly specify plan fee schedule allowances, annual maximums or limitations. It is more realistic to expect dental insurance to cover 35% to 65% of major services. Remember, the amount a plan pays is determined by how much the employer paid for the plan. You get back only what your employer put in, less the profits of the insurance company.
  • Fact #5: Many routine dental services are not covered by insurance companies.

Financial arrangements must be made directly with us, regardless of insurance coverage.

Please do not hesitate to ask us any questions about our office policies. If you have questions regarding your insurance benefits, please contact your employer or insurance carrier directly.

Understanding Your Dental Insurance Coverage

Responsibility for Payment

Your employer, management, or union has purchased dental insurance coverage from a selection of plans offered by an insurance company or broker. Each insurance company offers many different plans. The type of dental benefits that are covered relate to the dollar amount spent on the benefit package. Generally, the more money spent on a plan, the more services are covered. Most dental insurance covers only 50% to 80% of the cost of treatment. Major services (crowns, bridges, etc.), which are the most expensive dental procedures, are usually only covered at a 50% rate. For example, some dental benefit packages will not cover the fees for porcelain (tooth-colored material) crowns on teeth that are not visible when you talk or smile; they will only pay for a metal crown. Under this type of plan you must pay the full amount of the cost of the porcelain on those teeth. According to insurance companies, fillings in front teeth have both functional use and cosmetic components. They will pay for the functional part but not the full amount for the cosmetic restorations.

The fees charged for dental treatment reflect the many different parts of a particular procedure or procedures. Treatment for your particular needs may or may not fall within the limits set by your particular dental plan. Many dental procedures may not even be listed in your insurance’s procedure/payment schedule. If your dental procedure falls into this category, you may not receive any insurance reimbursement for that procedure. You are ultimately responsible for paying the entire fee for an accepted dental treatment, regardless of your insurance coverage.

Choosing Treatment Options

Our goal through your examination, diagnosis, and treatment phases is to provide you with the best possible oral health. We do not allow the insurance company to tell us how to treat you. We recommend to you those treatments that we believe you need and we will discuss alternative plans with you. Whether or not the recommended treatment is a covered dental benefit is between you and your employer and the insurance carrier.

Submitting the Claim

We are happy to help you receive the maximum benefits you are allowed from your dental coverage. In order for us to submit your insurance claim, we will need an insurance form with your portion completed and signed. We deal with many dental insurance companies on a daily basis; therefore, we have a great deal of experience submitting these claims to insurance carriers. We take great care in submitting claims properly the first time. There are three things we cannot do: 1) Alter the date of treatment; 2) Submit a claim for more than the actual fee; 3) Submit a claim for procedures that have not been performed. Because it is not at all uncommon for the insurance carriers to make a mistake, we would prefer to submit the claims ourselves, and then verify proper payment. Insurance carriers may respond to requests for payment of preauthorized treatment in as little as a week or as long as 45 days. Please be patient; we have no control over the post office or the speed with which the insurance carrier processes your claim. Our office cannot negotiate with your insurance company for reimbursement of dental expenses. Only the purchaser of the plan (your employer) can negotiate better coverage. If you would like better or more coverage, you will need to talk with your plan purchaser about the features you want in your dental plan.


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