Dental Benefits (Insurance)
If we have received all of your dental benefits information on or before the day of the appointment and we are able to confirm eligibility, we will be happy to file claims on your behalf. Accurate information is essential for proper claim filing.
We will do our best to estimate your portion of the fee for dental services performed in our office; however, any information received from your insurance company whether by phone or by pre-determination comes with a disclaimer stating that no benefits can be guaranteed prior to the processing of the claim, and therefore we are in no position to guarantee what your insurance company will pay on a claim.
Please understand that filing your claims is a courtesy our office provides for you, our patient. This in no way guarantees payment to us. We provide our professional services to you – not the insurance company. You are ultimately responsible for payment of our fees.
SOME FACTS YOU SHOULD KNOW ABOUT DENTAL INSURANCE
Fact 1 – DENTAL BENEFIT PLANS RARELY PAY 100% OF ALL PROCEDURES
Dental “insurance” is generally a benefit of employment and is generally an aid to receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. However, in reality most plans only pay between 50%-80% of the average total fee up to the maximum allowed per year. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage or the type of contract your employer has set up with the insurance company.
Facts 2 – YOUR BENEFITS ARE NOT DETERMINED BY OUR OFFICE:
You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist's actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist's fee has exceeded the usual, customary, or reasonable fee ("UCR") used by the company.
A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists in the area charge for a certain service. This is intentionally misleading and is simply not accurate.
Insurance companies set their own payment schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the "allowable" UCR Fee. These allowable fees differ from plan to plan and the same insurance company has multiple plan options to satisfy the requirements of different employers. The "allowable" fees are set by the insurance company and are determined so that the company runs at a profit.
Unfortunately, insurance companies imply that your dentist is "overcharging" rather than say that they are "underpaying" or that their benefits are low. 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 estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume a fee for a service is $150.00. Assume this is a “usual and customary (UCR) fee” according to the insurance company. When calculating an expected benefit, if there is a deductible (paid by you), it is subtracted, first. Fifty dollar deductibles are common and if we use that in this example after subtracting this from the fee of $150.00, the company will pay its plan benefit on the remaining $100.00. Say the plan pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less
Please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment.