Dentists know how important dental insurance benefits are to patients. Navigating the muddy waters of the dental insurance world is challenging, and our Grand Dental insurance specialists are happy to answer some of your most common questions.
Why doesn’t my insurance cover this?
There are many reasons why your dental insurance may not provide complete or any payment for services. Many patients are under the misconception that insurance pays almost all or 100% of their dental costs. This is not true as most plans merely pay 50-80% of the average total dental fee. Some pay more, others less. The percentage paid by your insurance is determined by the amount you or your employer has paid for coverage or the type of contract your employer has agreed upon with the insurance company. Benefits are not determined by your dental office, but rather the insurance policy. This also holds true for the type of procedures your insurance will cover. Preventative, diagnostic, restorative, major dental, periodontal care, oral surgery, and orthodontics are common sub-categories in your dental insurance policy. How much benefit you receive for these services depends on your insurance plan. A plan that pays 100% of preventative and diagnostic procedures such as cleanings, x-rays, and fluoride may still limit who can receive these services and how often. Fluoride treatments for children might be allowed, but not for adults. A patient who has two routine exams in one year might not receive insurance payment for an emergency dental exam, etc. It is important to thoroughly read through your insurance policy to understand these details. Your dental office’s insurance specialist should be able to help you.
What does “Usual and Customary” or UCR mean?
Sometimes your dental insurance company reimburses your dental provider at a lower percentage than the office’s actual fees. Insurance companies state that the reimbursement is reduced because your dentist’s fee has exceeded the “usual, customary, or reasonable” fee used by the insurance company. This statement gives the impression that any fee greater than the amount paid by the insurance company is unreasonable, or well above what most dentists in the area charge for a certain service. This is misleading and inaccurate. Insurance companies create their own fee schedules, and each company uses a different set of fees that they consider allowable. Each company arbitrarily selects the level they determine to be the usual, customary, and reasonable (UCR) fee. Frequently, the insurance company’s data is 3-5 years old and the fees are set so that the insurance company can net a 20-30% profit.
Unfortunately, insurance companies often imply that dentists are “overcharging” rather than admit that they are underpaying or that their benefits are low. In general, a less expensive insurance policy will use a lower usual, customary, and reasonable set fee. Patients who want to receive more benefits from their insurance typically must spend substantially more for the policy and pay higher premiums.
What are deductibles and co-pays?
Deductibles are the amount your insurance company expects you to pay before they pay out any benefit dollars. The deductible is set by your insurance and can be either an individual or a family amount, or both. Co-payments are the amount for which the patient is responsible. Your insurance company sets “co-pay” percentages on dental procedures. These co-pay amounts differ by insurance company and the type of dental service provided. Your co-pay can be as much as 100% of the service, or as little as 0% of the procedure. Your specific insurance plan determines this.
What is “out of pocket” mean?
Your “out of pocket” costs refer to the amount of money you have to pay for your dental treatment. Deductibles and co-payments should be considered when estimating out of pocket expenses. Your out of pocket costs will depend on if you have met your family or individual deductible, what your co-payment percentage for the specified procedure is, the dental provider’s fee, and what your insurance deems as the UCR.
Do you have additional questions about your insurance? Contact our insurance experts today at any of our Grand Dental locations!
Use Your Dental Insurance Before It Expires
If you are wondering when you should use your dental insurance benefits, the time is now! Not everyone has access to dental insurance but for those people who do, we strongly recommend that you consider utilizing your insurance money before the end of the year.
At Grand Dental Group, our insurance specialists know that most dental insurance companies have a “use it or lose it” policy. This means that your left over insurance benefit dollars will not rollover. Any unused money is lost to the insurance companies themselves. Nearly all dental insurance companies have benefit plans that run on a calendar year. Therefore, by January 1st, your remaining benefits will be lost. If you have dental insurance, it is important to know that your dental benefits typically expire at the end of the year. You forfeit those dollars per your insurance company’s policy.
Patients can contact their insurance company or dental office to verify if their insurance policy is a calendar or fiscal year plan. Since employers or patients themselves pay premiums to have dental benefits, it is in the patient’s best interest to maximize these benefits and receive the most for their hard-earned premium dollars. Dental offices often become quite busy near the end of the year and holidays. Patients using their insurance benefits will be competing for appointment times along with children who are off of school and patients with last-minute dental emergencies. It is best to contact your dental office to make an appointment as soon as possible to avoid the scheduling crunch.
When considering whether or not you should schedule dental appointments before the end of the year, keep in mind the following points:
- Have I met my individual or family deductible for the year?
- Have I taken advantage of two hygiene teeth cleanings and dental check ups this year for both me and my family?
- How much insurance benefit money do I have remaining? Will I lose that money by January 1st?
- Do I have any dental treatment needs that I can schedule to allow me to better utilize my insurance benefits while also preventing more significant dental problems next year?
- If I have extensive dental needs, what can I do this year to maximize my dental benefits while keeping my out of pocket costs low?
- Do my school-aged children have sealant coverage and can I utilize my insurance for that preventative service?
- Does my high school or college-aged dependent have any issues with his other wisdom teeth that may require treatment?
- Do I have any dental needs that I can treat today in lieu of “waiting and watching”?
These are just a few of the questions and points to help patients understand how and why they should use their insurance benefits before the end of 2015. Many times patients and families have more insurance benefits than they realized they still had available. Your dental office should be able to assist you with answering your insurance questions and helping you maximize your benefits as well. December is already here, so don’t delay in making that call!
Many Americans wonder: what is the best dental insurance for my family? This is a challenging question and can be a daunting task. Navigating the rough waters of the dental insurance industry is tricky, at best. When companies provide dental insurance benefits for their employees, the difficulty of finding a plan is already handled for the worker and their family. However, for many Americans without dental insurance, choosing a plan that will benefit your family can be overwhelming.
Grand Dental Group administrative staff and insurance specialists are asked these questions often and have some general tips and advice for people seeking dental insurance.
Dental Insurance rarely covers all procedures
First, it is important that families understand that dental insurance is really more of a discount plan. Dental insurance rarely covers all procedures, and often only provides a percentage of payment on procedures that are covered under the plan. Waiting periods on major dental and specialty services is also common. Individual and family dollar maximums are almost always a given, and usually top off at no more than $1000-1500 a person for a year.
Families should weigh their expected dental needs and costs with the costs of dental insurance premiums and plan benefits. For example, families who acquire insurance to help cover braces for their teenager might find that their plan only covers $1000 of orthodontic treatment or that there is a 1 year waiting period before the plan will pay. Individuals or couples who have few dental needs may discover that plan premiums are more costly than paying out of pocket for routine preventative dental check-ups and cleanings. Furthermore, many insurances do not offer any benefits for services such as adult fluoride, certain periodontal disease therapies, dental implants, etc. Determining your family’s needs and what dental services you would like covered will help you make decisions about different plans.
How to choose a dentist
Another idea is to contact your current dental home or find a dentist that your family is comfortable with. If you like the office and their team, ask the office with what dental insurance companies their office is contracted. From there, you can contact or search those specific insurance companies online. Review waiting periods, deductibles, plan benefits, covered services, and family maximums. If you find a plan that meets your needs, fits within your budget, and is also accepted at your favorite dental office- it’s a win for everyone!
Your friends and family can also be a good source of information. People are very honest about their satisfaction or dissatisfaction with their dental insurances and dental offices. If you have friends or family members who have purchased their own dental plans, they can be a wealth of information.
Ask your dentist about your insurance
When in doubt, contact your dentist. A good dental office will answer your insurance questions and even review potential policies with you. Since dental administrative staff work most closely with insurance plans, their advice and insight is invaluable. Dental insurance typically does not cover all procedures at 100%. It is common to have out of pocket costs, no matter what the plan is. However, a good dental insurance plan will provide maximum care, with the least amount of restrictions and waiting periods, at a reasonable cost to the individual and family. Emergency care, orthodontic treatment, oral surgery, etc., may result in unexpected costs that are not covered by your insurance. However, Grand Dental Group, and many other dental offices offer payment plan options and Care Credit that allow you to proceed with needed dental treatment while reducing financial stress on your family.
Most patients find dental insurance policies confusing and for good reason! It is not easy to navigate the legal jargon and technicalities that are typical of most dental insurance plans. Misinformation often leads to a confused, frustrated, or angry patient and many times the patient might mistakenly blame their dental office as the source of the problem. In fact, for patients with insurance issues and unexpected dental bills, it is typically a misunderstanding of their own dental plan that causes the confusion.
Dental Insurance Information
At Grand Dental Group, our goal is to help clarify the muddy waters of insurance plans and service billing and coding. At our dental offices, we provide the courtesy of filing your claim for you, provided that we have received correct and complete information from the patient. We recommend that patients become familiar with their insurance benefits, so as to be better prepared for out-of-pocket expenses and fees not covered by insurance at the time of their visit.
Dental insurance is meant to be an aid in receiving dental care. Many patients are under the misconception that insurance pays almost all or 100% of their dental costs. This is not true as most plans merely pay 50-80% of the average total dental fee. Some pay more, others less. The percentage paid is usually set by the amount you or your employer has paid for coverage or the type of contract your employer has agreed upon with the insurance company.
Benefits are not determined by your dental office. You may have noticed that sometimes your dental insurance company reimburses your dental provider at a lower percentage than the office’s actual fees. Insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (UCR) used by the insurance company.
This statement implies that any fee greater than the amount paid by the insurance company is unreasonable, or well above what most dentists in the area charge for a certain service. This is misleading and inaccurate.
How do insurance companies operate?
Insurance companies create their own fee schedules, and each company uses a different set of fees that they consider allowable. These allowable fees may vary greatly. Each company arbitrarily selects the level they determine to be the usual, customary, and reasonable (UCR) fee. Insurance companies gather data from their own insurance claims to create this UCR fee schedule. Frequently, the insurance company’s data is more than 3-5 years old and the fees are set so that the insurance company can net a 20-30% profit.
Unfortunately, insurance companies prefer to imply that dentists are “overcharging” rather than admit that they are underpaying or that their benefits are low. In general, a less expensive insurance policy will use a lower usual, customary, and reasonable set fee.
eductibles and Co-Payments should be considered when estimating the patient’s out-of-pocket expenses. Your insurance plan deductible is also set by the policy you or your employer selected and is paid by the patient before insurance benefits are applied. For example: If your dental service is $200 and your deductible is $100, then you would be responsible for $100. For the $100 remaining, if your insurance policy pays 80% of the service, then $80 would be paid by your insurance, leaving the remaining $20 as the patient’s portion. If your insurance company’s UCR is lower or if your benefits are less than 80% coverage, than your insurance payment would be lower and your out-of-pocket responsibility would be higher.
At Grand Dental Group, we have insurance specialists available as a courtesy to answer your dental insurance related questions and handle your concerns. When in doubt, call us or ask to speak to a staff person and we will assist you in navigating the confusing world of dental insurance.
If the Dentist says I need it, why doesn’t my insurance cover it?
This is one of the most common insurance questions we hear in our offices. Insurance policies and their fine print can be confusing to most of us and we understand how difficult it is. We also understand how frustrating it can be, so let us help explain how situations like this happen:
There are times when a dental procedure or treatment may be recommended that insurance will not cover. The perception insurance companies give is, that if it is not covered, it can’t be that important. That simply is not true. Most of the time it is not the insurance companies who make these decisions, but it is the employers who are responsible for choosing the specific insurance plan. Employers want to keep medical and dental premiums and costs down for their employees. And in order to do that, they need to carefully select the coverage under your plan. To keep the cost down, not all treatment can be a covered expense or if it is, it may have specific guidelines it needs to follow in order to be covered.
Think of it like buying a car, you start at a basic model and then each additional feature you add on brings the cost up. The dental insurance plan works much the same way. This explains how a situation can arise where some of the dental procedures you might need would not be covered under your dental plan. Insurance plans can range from very basic with little benefit, to extensive plans that offer a larger benefit for most dental procedures. However, the difference in premium cost between the lowest and highest level of plan can be huge. If your employer is trying to minimize his/her premium costs towards your dental plan, your plan may not provide coverage for even some of the most basic and commonly performed dental procedures.
Dentists are educated and have an ethical responsibility to recommend the treatment you NEED, not the treatment that your insurance policy would cover. This complicated problem is also why a dentist or a doctor would be doing you a disservice, if they only recommended treatment that insurance covered.
Grand Dental Central Business Office
Many of our patients have dental insurance benefits, but understanding those benefits can be difficult. Our offices have insurance specialists in place to assist our patients in getting the most out of their benefits and obtaining the highest level of allowed reimbursement. We try to explain the challenging process of filing dental insurance claims to our patients whenever we have the opportunity. For example:
“I paid what they told me to pay at the front desk when I finished my treatment; I have insurance—how come I just got a statement in the mail from my dentist?”
That is a question we hear all the time, and we understand the frustration and confusion that comes from complicated insurance claims. Let us clarify the process better for you:
When a patient makes an appointment for dental treatment, the insurance team quickly verifies coverage and calculates the estimated coverage level. The operative word in this situation is estimate. Many insurance companies will give dental offices some information, but most insurance companies will not commit to firm benefit information, even when it is requested. Many things factor into the amount of reimbursement benefit that an insurance company will provide. Dental insurance companies, not dental offices, determine the level of benefits that the patient receives.
Until the treatment is completed, and the paper work is submitted, the amount of reimbursement that an insurance company will provide is an educated guess. Once the claim is processed, and the insurance company sends the dental office reimbursement for your treatment, the payment is then applied to your account. If after insurance benefit reimbursement is applied a balance is due, a computer account statement will be generated and mailed out to the patient. If the insurance benefit reimbursement check exceeds the amount due, the credit will be applied to the patient’s account.