Understand Your Dental Insurance and Our Financial Policy

If we have received all of your insurance information before or on the day of the appointment, we will be happy to file your claim for you. Before your visit to our dental office, it’s advisable that you get familiar with your insurance benefits, either through your HR department or visiting insurance company’s website, as we will collect from you the estimated amount insurance is not expected to pay. Payment is expected as services are rendered unless prior financial arrangements have been made. By law your insurance company is required to pay each claim within 30 days of receipt. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. We will be glad to send a refund to you once insurance has paid us.

Also, please understand that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are NOT responsible for how your insurance company handles its claims or for what benefits they pay on a claim. Although we thrive to provide accurate information, we can only assist you in ESTIMATING your portion of the cost of treatment based on our experiences, we can’t guarantee what your insurance will or will not do with each claim. We also can not be responsible for any errors in filing your insurance, once again we file claims as a courtesy to you.

Here are some facts regarding your dental insurance.

FACT #1: NO INSURANCE PAYS 100% OF ALL PROCEDURES.

Many patients think if they have dental insurance, then the insurance company will pay 100% of all dental fees. This is not true! Dental insurance is meant to be an aid in receiving dental care. Most plans may fully cover preventative and diagnostic procedures, which implies no out-of-pocket charge when having regular checkup and cleaning within the plan limitation. But on average insurance companies pay only between 50%-80% of the total fees of dental treatments, such as filling, extraction and crowns. Some pay more, some less. Even if you have dual insurance coverage, you may still be responsible for some portion of the costs.

The percentage paid by the insurance company is determined by the terms of a contract between your employer and the insurance company and the amount you and your employer has paid for coverage. If you purchase an individual dental plan, you should also receive a booklet of the fee schedule and/or the coverage you purchase Also, deductibles and co-payments must be considered when determining you portion due. Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. 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.

Fact #2: YOUR DENTAL 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.

An EOB (explaination of benefit) 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 can be very misleading and simply is not accurate.

Insurance companies set their own 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. Frequently this data can be three to five years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit.

Some insurance companies set fee schedule for their contracted dental service providers. These fees are normally shown in the dental benefit booklet for subscribers. Even your dental insurance states a 100%-coverage on certain service, patient will still have to pay the difference between standard service chrage and the fee that is usually much lower.

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 unless your individual or family deductible has been met. To illustrate, assume the fee for a certain dental service is $200.00. Assuming that the insurance company allows $200.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $150.00. Assuming the coinsurance percentage under this dental is 80% for this particular procedure. The insurance company will then pay 80% of $150.00, or $120.00. As a result, out of a $200.00 fee they will pay an estimated $120.00 leaving a remaining portion of $80.00 (to be paid by the patient). Of course, if the UCR is less than $200.00 or your plan pays only at lower rate, say 50%, then the insurance benefits will also be significantly less.

MOST IMPORTANTLY, please always keep us informed of any insurance changes such as subscriber’s (policy holder) name, policy number, insurance company, address, or a change of employment.