DENTAL BENEFIT (INSURANCE) INFORMATION
As a part of Sink Family Dentistry, we are committed to providing you with the highest quality care and service. Because we are also concerned about the rising cost of healthcare, we make every effort to provide services in an efficient manner, reducing costs to you, the patient. We are happy to help you maximize reimbursement from your dental benefit provider; however, we must emphasize, as a health care provider, that our relationship is with you and not your insurance company. Often the assumption is made that if a person has insurance, then it is the insurance company who owes the doctor for his services. This assumption is incorrect. Insurance is a contract between you, your employer and your insurance provider – we are not a party to that contract. As a courtesy, we file insurance claims on behalf of our patients, however, all charges are your responsibility from the date services are rendered until paid in full.
Patient Payment
Insurance companies and plans differ in their policies regarding coverage of services that a dental office may provide. For this reason, your policy may require you (the subscriber) to pay nothing, a deductible, co-pay, and co-insurance or may require you to pay for the entire procedure, depending on the policy. Please remember that most policies do not cover the full cost of procedures including cleanings. Insurance companies usual pay between 50-80% of costs under the maximum annual benefit (usually $1000 -$1500) and only after your yearly deductible have been paid. Dental “insurances” are designed to reduce your out-of-pocket expenses but not to eliminate it completely.
Estimate of Benefits
Based on what many insurance companies cover for a procedure, we estimate the amount you may owe our office for your visit.This is only an estimate. Payment for services is only determined after services are rendered, a claim is sent to your insurance, and the insurance company reviews the claim, which can take several weeks. It is impossible for an office to know every insurance company's multitude of plans’ rules, but we do our best to provide you an accurate estimate.
Predeterminations
At your request, we can submit for a Pre-Determination of Benefits before treatment is rendered. Response time to receive information back from an insurance company is approximately 4-6 weeks. A pre-determination does not guarantee an insurance payment; it is only a slightly more accurate way to attempt to determine what benefits are included in the policy that was purchased by your employer.
FAQs about Dental Benefits
Why isn’t my dental insurance covering all of my treatment costs?
While the name can be misleading, dental “insurance” should really be referred to as dental benefits. Medical insurance is a payment used to cover the cost of loss. Your dental “insurance” is really a monetary benefit, usually provided by your employer, to help pay for routine dental care. When your employer purchases a dental plan, it is based on the amount of benefit and premium costs. The majority of dental plans are only designed to cover a portion of the total treatment cost.
What does this mean for the me?
Because the dental benefit is small, it is rare for a patient’s dental benefit plan to cover the entire cost of care. Some procedures on a single tooth or prosthesis can surpass the total maximum benefit. While we try to predict what your benefits will cover, your company may have rules that are unusual – some do not have crown coverage at all, some have a waiting period, some will only cover a crown if the tooth has lost >50% of its structure. It is impossible for an office to know every insurance company and their multitude of plans’ rules, but we do our best to provide you an accurate estimate.
How does my dental benefits carrier decide the allowed payments?
Often carriers refer to their allowed payments as UCR (usual, customary and reasonable). However, this can be very misleading and not mean exactly what it stands for. The UCR is a listing of what that insurance company allows for payment for all covered procedures between your employer and the insurance company. Often, this list has not been updated in 10+ years. Also, this listing reflects the cost of premiums based on your city and state. More than likely, your employer has selected a UCR payment amount that is in relation to the premium cost they desire.
If there are always out-of-pocket expenses, what good is it to have dental benefits?
While your plan may not cover the entire portion of your treatment, it still covers something. Usually, routine cleanings will be almost completely covered twice a year. Anything it does help to pay will reduce your portion. It does help to have it!
My dental benefits have an annual maximum. Why?
Your maximum limit is what is required by your carrier to cover each year. Surprisingly, while costs for dental services have steadily been rising, dental annual maximums have not changed much since the 1960s.
Why won’t my insurance pay for some procedures such as x-rays, cleaning and gum treatments?
Your dental benefits contract will specify how many of certain types of procedure they will cover annually. They limit the numbers of items such as x-rays, cleanings and gum treatments they will cover in one year due to the fact many people need to have these done more frequently than others.
I received an Explanation of Benefits (aka EOBs) from my dental benefits carrier, it states that my bill exceeded the UCR (usual and customary and reasonable). Does this mean you all charged more then you should have?
Good question. Keep in mind what dental benefit carriers call usual and customary is really just the amount negotiated by your employer and the carrier. Usually, it is less than what the dentists in your area might actually charge and does not mean the dentist is charging too much. Often, the UCR amount is an estimate from 10+ years ago and does not reflect today’s costs.