Wednesday, July 3, 2013

DENTAL INSURANCE 101

I decided to put this in question form so it's easier to follow.  The questions below are the ones I hear most frequently when it comes to dental insurance in our office.

Q:  Why doesn't my insurance cover all the costs for my dental treatment?
A:  Dental insurance isn't really insurance at all.  It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment.  Another way to look at it is a coupon to use to pay a portion of your costs.

Q:  My plan says that my exams and certain other procedures are covered 100%.
A:  That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge.  For example, say your dentist charges $145 for an examination.  Your carrier may allow $100 as the 100% payment for that examination, leaving $45 for you to pay.

Q:  If I always have a balance to pay, what good is my insurance?
A:  Even a benefit plan that doesn't cover a large portion of the cost of needed dentistry pays something.  Any amount covered reduces what you have to pay out of pocket!   Those who don't have dental insurance, which is typically 40-60% of the population, have to pay the TOTAL amount.  So be thankful if you do have dental insurance benefits.

Q:  How does my insurance carrier come up with its allowed payments?
A:  Many carriers refer to their allowed payments as usual, customary and reasonable or UCR.  However, usual, customary and reasonable does not really mean exactly what it seems to mean.  UCR is actually a listing of payments for all covered procedures negotiated by your employer and the insurance company.  It has no bearing on what your dentist's fees are.  It doesn't mean your dentist is charging more than others are.  This listing is related to the cost of the premiums and where you are located in your city  and state.  Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire.  UCR payments could be more accurately called negotiated payments.

Q:  I received an Explanation of Benefits from my insurance carrier that says my dental bill exceeded the usual and customary, UCR.  Does this mean that a dentist is charging more than he/she should?
A:  Remember that what insurance carriers call usual and customary is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment.  It is usually less and frequently much less than what any dentist in your area might actually charge for a dental procedure.  It does not mean that your dentist is charging too much.

Q:  Why are you, Dr. Fauth, not on my benefit plan?
A:  The dentists on the list have agreed to a contract with the benefit plan..  These contracts have restrictions and requirements.  For instance, I don't join plans when I'm not comfortable with the restrictions or their payments are so low I can't continue to provide the best quality dentistry I desire for my patient.  I don't want to cut any corners when it comes to doing it right.

Q:  Why won't my plan pay anything toward some procedures?
A:  Your employer or group has decided how many procedures and how much they will pay annually.  As in many areas of life, there are good dental plans and, quite frankly, not so good ones.

Q:  Why do some benefit plans require me to select a dentist from a list?
A:  Usually a dentist on the list has agreed to a contract with the benefit plan.  These contracts have restrictions and requirements.  Many insurance companies call these lists "preferred providers".  This is a misnomer.  They aren't better dentists; they are dentists the carriers prefer you go to.  If your dentist is not on the list it doesn't mean that something is wrong with the dentist or the office.  It usually means the insurance company's benefits pay too low to continue providing the kind of quality dentistry they desire.

Q:  What should I do if my insurance doesn't pay for treatment I think should be covered?
A:  Because your insurance coverage is between you, your employer and the insurance carrier, your dentist does not have the power to make your plan pay.  If your insurance doesn't pay, you are responsible for the total cost of treatment.  Sometimes a plan may pay if patients send in a claim for themselves.  The Employee Benefits Coordinator at your place of employment may be able to help.  Patients may also lodge complaints with the State Insurance Commission.

Hope this sheds some light on this subject!

1 Comments:

At February 11, 2019 at 7:19 AM , Blogger Amy Watson said...

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