Dental insurance has not changed much since its inception as an add-on benefit to medical insurance in the 1970’s. However, unlike medical insurance, dental insurance has not increased its benefits consistent with cost of living inflation. In today’s dollars, your benefits are significantly less than when dental insurance was first introduced. Insurance companies are also increasingly disputing or denying well-documented, needed treatments, and every insurance company differs in how it applies their own rules. We cannot emphasize enough that we can only ever provide an estimate of your insurance benefit because we cannot always predict what your insurance company will decide to pay on. While dental insurance may offset some costs of dental treatment, it should not be the deciding factor on your treatment option.
Dental insurance can be confusing and is often misleading for patients. If you have dental insurance that you purchased individually or provided by your employer, we can try and help you to understand your benefit coverage if you provide us with the accurate subscriber’s information in advance of your appointment. Please understand that at the end of the day your insurance agreement is a contract between you (not the dentist) and your insurance carrier. The patient is ultimately responsible for the account regardless of insurance coverage.
As a courtesy, we file your claim for you and accept direct payment from most insurance companies. We will estimate your deductible and your copayment based on the information relayed to us by your insurance company. Once the claim is processed, our estimates may at times be different than previously expected if your insurance company decides to give alternate downgraded benefits or no benefits towards a procedure that was rendered. Most insurance companies will pay for the least expensive option; not necessarily the best one available to the patient. We cannot guarantee payment from your insurance company on all procedures needed or recommended, but we will always recommend the best treatment options for your oral health.
To help you understand more about insurance practices, here are some facts about today’s dental insurance marketplace:
- 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 almost all plans. At one time these deductibles were never taken out of preventive treatment (“exams, x-rays”). 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 or individual. The higher the premiums paid, generally the greater the dental insurance benefits.
- Even if there is a predetermination of benefits provided by the insurance carrier, it is possible that after treatment is provided, there are no insurance benefits payable.
- Each insurance company has their own criteria for when a procedure will be covered. This is not always based on the patient’s actual dental health need. And, when they do cover a procedure, insurances typically reimburse for the least expensive treatment option when better options exist and are recommended by your dental practitioner.
- 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.
- We (the dental office) have absolutely no influence or leverage to deal with the insurance carrier. Only the employee or the contract purchaser has that power. Any complaints about benefits, payment, or coverage should be directed to Human Resources or the company owner. Coverage may be increased by purchasing a higher premium plan.
- The letters “UCR” on insurance vouchers stand for Usual, Customary, and Reasonable. 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. A single insurance carrier may have a dozen different UCR fees for the same procedure, same office, and same dentist.
- Your dental benefits almost always have a yearly maximum contribution level. 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 typical maximum contribution level has not been updated for inflation in the intervening period, and, as a result, your maximum covers significantly less in today’s dollars.