Many people are often confused by the language placed in insurance pamphlets and booklets. Most people seem to think that dental insurance is there to cover 100% of any service provided by your dentist. This is in fact FALSE. “The amount your plan pays is determined by the agreement negotiated by your employer with the insurer” (ADA)
I myself have been dealing with dental insurance companies for 3 years now. I can tell you from direct experience that NO INSURANCE COMPANY PAYS 100%. Insurance companies like to use tricky language to deceive the average policy holder. A simple tip to remember is that even though your insurance may not cover what is expected, you have had a service performed.
- In network: A dentist who agrees to be “in network” with an insurance company agrees to accept a certain set of fees that are determined by the insurance company. Typically, your insurance company will give you a list of “preferred providers” or in network dentists in your area. An example of a claim that may be filed is usually for a cleaning and exam. The fee for a cleaning and exam in this situation is $100. A dentist who is in network will accept the insurance payment of $90 and write off the remaining $10. This will leave no balance to the patient.
- Out of Network: 90% of the time you will notice that the dental insurance you have may not be “in network” with the doctor that you have been seeing. I’d like to say that for many people this is the beginning of the insurance battle that they may face. If you take the same example of $100 for a dental cleaning & exam, the insurance company paid $90. The remaining $10, would be YOUR balance. The doctor has not signed a contract to participate with the insurance company and thus will leave you a balance. While a company may be out of network they can still process your claims and your out-of-pocket may be the only difference.
- A very deceiving trick that insurance companies tend to use is to say that your breakdown is 100% for a cleaning and an exam. THIS IS NOT TRUE! They will pay 100% of their fee schedule. A fee schedule is the total amount that an out of network insurance company is willing to pay. In many cases they will pay 100% of the allowable( fee schedule) which may be the $90.
- Annual Maximums: Most dental insurance companies have an annual dollar amount to which they will pay. They will not pay a single cent over this amount!!! Even thought the cost of many dental procedures has risen, the dental max for many plans have stayed the same. Talk to your HR rep or insurance agent to find out what plans are available to you.
- Plan Limitations: While in a perfect world it would be nice to have a plan that pays for 6 cleanings a year and covers 100% for crowns……However, we do not live in a perfect world. Each plan has certain stipulations that limit the amount of cleanings each of us can have per year. This applies to almost every service your dentist provides for you. Consult your insurance company for specific plan provisions BEFORE your treatment is provided in order to avoid a problem with declined coverage. Most offices will send a pre-treatment (PTE) estimate for you in order for an exact estimate of benefits
Lastly, it is important to not get upset at your doctor for problems with YOUR insurance.Insurance is not between the doctor and you , it is between you and the insurance company. Placing blame on your doctor or his staff causes the relationship between you and them to be strained. Please learn your plan before getting upset with your office. Many times it is near to impossible for an impromptu estimate to be perfect because every plan is different! If you are unsure of your plan please contact the insurance company or make sure to have your office get your benefit before services are provided.
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