For Our Patients; Helping You Through the Insurance Maze:
During the past decade, dental benefit plans have become an integral part of health care planning for many families. Dental benefit plans are made available to employees or members through companies, unions and associations and may vary considerably from one plan to the next.
The range of benefits depends solely on what the purchaser wishes to offer employees or members. Some plans may cover as little as 30% or as much as 100% of dental services with most falling in the 50% to 80% range. Some plans exclude certain types of services (e.g., orthodontics or implants) while other plans will cover a full range of dental services.
As the number of patients covered by dental benefit plans has increased, certain assumptions have become evident and we would like to make the principles of our practice, as well as the type of service and care we provide our patients, very clear:
- Our fees are based on the overhead involved in our practice, the treatment plan selected and the time it takes us to provide you with the necessary dental care. We do not believe it is in either of our best interests for us to compromise our recommended treatment in order to accommodate an insurance program’s benefit schedule that may be considerably less than optimal. However, we are more than happy to discuss a treatment plan’s advantages and alternatives with you, thereby involving you, rather than your insurance company, in making decisions about what is best for you.
- The type of treatment you need and receive from us is based upon our professional judgment and not on whether you are covered by a dental benefit plan.
- If your dental benefit plan requires a “predetermination” or “prior authorization”, we will submit a treatment plan for review by your insurance carrier. However, please remember that our relationship is with you, not your insurance carrier. You and your employer pay their premiums and they have an obligation to you, not us. Through experience, we have learned how to help you gain maximum allowable benefits and we are happy to do so. But please remember that the ultimate financial obligation for the services we provide is between you and our office.
- Dental patients sometimes receive communication from their insurance carrier that a fee is over and above the usual and customary rate (UCR) for the service provided. Before you believe that, please understand that there are wide variations in the methods used by carriers to arrive at these figures. Many carriers do not update their figures regularly and many don’t even relate to specific fees in the St. Louis County area. In one study, the UCR determinations made by carriers for the same procedure in the same city at the same time differed by as much as 136%.
- Also, keep in mind that the preauthorized estimate of benefits is not always a guarantee that the exact amount given will be what your carrier pays. Things like changes in patient eligibility, frequency limits, deductibles, other claims submitted by another dentist and secondary coverage of a spouse can all affect your reimbursement. We don’t control the fine print in your policy but our staff is experienced and we can help you understand it.
- Most plans include a yearly maximum on benefits. Once you reach the maximum, your coverage stops until the next year. And, if you don’t use all of your benefits for a particular year, they’re lost forever because they don’t accumulate into the next year. Treatment can often be coordinated to help you gain maximum utilization of your insurance plan.
- When we provide a service with a fee greater than $250.00 that your insurance carrier has given “prior authorization” for, you will be responsible only for your copayment amount at that appointment. When the insurance payment is received, we will reconcile the actual amount and let you know what the difference is.
- If you believe that the dental benefits provided by your plan are inadequate, you may want to discuss the matter with your employer, union or association so that appropriate alternatives can be investigated.
We will help you in every way we can in filing your claims, handling insurance queries, processing follow-ups, lost claims, etc. No question is too small for you to ask, whether it is about your treatment, benefit plan or statement. We are here to help you!