dental insurance claims notebook
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"Is my insurance company/policy good?" is a question I get asked a lot. To be perfectly honest, it's actually difficult for us to answer that question. Here's why . . .

From my perspective a "good" insurance company/policy means that they pay what they say they will pay, on time, and without requiring a lot of additional, often even unnecessary, paperwork. From your perspective, "good" means that your out-of-pocket expense will be low, but the coverage of procedures and frequency will be high.

If you are fortunate enough to have dental insurance, it's important to be aware that the coverage is based on the policy that your Human Resources department negotiated with the company. This decision is typically based on financial considerations. As such, there are so many different policies, that it is often nearly impossible for your dental office to know what is covered and what is not.

Dental Insurance Can Help Pay for Treatment, but It Has It's Limitations

Every dental insurance policy has a maximum dollar amount that they will pay out for a 12 month period (which is not always the standard January to December calendar year). This can range from $1,000 to $2,000 depending on the plan.

Most insurances will also have an annual (occasionally lifetime) deductible which can range from $50-$100. However, this does not kick in until you are sitting in my chair, the deductible is waived for preventive and diagnostic services. It's also important to remember that unlike a lot of cell phone carriers, there is no 'roll over' option, so if you have met your deductible, schedule any outstanding treatment before the end of the year. You might think that the holidays are about decorations and last minute shopping but in my office it's the twelve days of root canals and last minute crowns.

There are also limitations on the frequency of certain procedures (typically preventive care), time limits on the replacement of existing restorations (crowns, dentures etc.), and there may be restrictions due to a waiting period if the insurance is new (anywhere from 6-12 months and typically for major procedures). Certain services also have age limits (fluoride, orthodontics are most common).

Stay Classy!

Dental insurance plans usually organize and separate procedures into different classes on a scale of I to IV. Here's how it's often broken down:

Preventive/Diagnostic Procedures (exams, x-rays and cleanings)
These services are typically covered at 100%. Often patients will refer to these visits as "free" since there is no co-payment. "I only want to do my two free cleanings a year," is what you say - but the reality is that you have pre-paid for these appointments - you are paying for them right out of your paycheck. As with everything, there is always an exception to the rule, and we are starting to see some insurance companies re-classifying the Panoramic x-ray (the one usually covered every 3 or 5 years) as a "Basic" procedure.

Basic Procedures (fillings, extractions, root canals and periodontal cleanings)
These services are generally covered at around 80%, but it can vary anywhere from 30% to 90%. In the last few years, some insurance companies have been "assigning an alternate benefit" which basically translates to this: you come in for a nice white filling on a back tooth, pay your 20% and wait for insurance to pay their 80%. Then you end up getting a bill for more, because it turns out the insurance company has assigned an alternate benefit because they are only willing to pay 80% of a silver (amalgam) filling on a back tooth which, surprise, surprise, costs less than a nice white filling. Since most dental offices are amalgam free, and most people are trying to replace their silver fillings with white, this practice has had a fairly lukewarm response from the consumer.

Major Procedures (crowns, bridges, dentures and partials)
These services tend to have a higher fee, and therefore a lower reimbursement rate. With dental insurance the more a procedure costs, the less they cover and the more you pay out-of-pocket. This is totally opposite to the way medical insurance works, but more on that below. The typical coverage for major procedures is 50%. However, I've seen some plans go as low as 30% and I once saw one go up to 60% coverage.

Orthodontic & Cosmetic Procedures (braces, ClearCorrect, whitening, bonding)
Not every dental insurance has an Orthodontic component, so it is always important to check and make sure before the wires go on! And some procedures are simply never covered - these are generally elective, cosmetic services like veneers and bleaching. Your dental insurance does not care to finance your new 'Hollywood Housewife' smile.

The "In" Crowd

One of the most common misconceptions about being "in" (or "out") of network is that if you are "in" there will be no co-pay for any procedures. Ever. The reality is, no matter which side of the network fence you are on, there will ALWAYS be some sort of financial responsibility due to the patient for certain procedures. How do you get a dentist's blood pressure up? Ask him about PPO's 'dictating treatment.'

Most dental offices will file your insurance (usually electronically) for you, and payment is sent directly to the provider. However, there are some insurances that will send a check to the patient, who is then responsible for reimbursing the dentist. In cases like this, many offices will have the patient pre-pay for their entire procedure to avoid any issues with "lost" checks.

Comparison Shopping Will Net You A Difference, But It's Not Always What You Expect

Price comparison shopping makes sense when you are looking to spend money on a 'product' like a gas BBQ, a lawnmower, or a new hot tub. However, dentistry is a 'service' because it is based on the labor, skill and education of a single individual. For example, you can go to Lowes and buy a bath tub, pipes and associated products, but without the skill and training (or a really, really comprehensive YouTube tutorial), you are going to need to invest in the services of a plumber.

Unlike filling up your car at the gas station, dentists can't just decide what they want to charge for a particular procedure. We are required to submit our desired fees for every single procedure code to the American Dental Association and they will either approve or deny them. They are looking at fees that are charged by all dental providers in the area. This safeguards against over or undercharging, thereby protecting both the consumer and the business owner. However, there will be a difference between treatment fees in a metropolitan area versus a more rural area. I had one patient drive 45 minutes up from Portland to get his implants done because of the price differential. I was expecting him to return to his local dental office, but he decided to switch because he liked my philosophy and staff. His family all wound up transferring here, too. We love it when that happens because it means we're succeeding at providing exceptional service.

Health & Dental: What's The Difference?

A dental insurance policy is very different from a medical insurance policy, so trying to compare the two is a bit like trying to pit Betty White against Joan Rivers. So I will let someone far more articulate explain the key areas in which they differ:

Bottom Line

dental office paperwork The bottom line is that we all have a bottom line. Your dentist and the entire staff should be equipped, and willing, to explain all of your options whether you have dental insurance or not. The reality is that we understand just how intensely irritating dealing with insurance can be for you, it's often quite irritating for us, too.

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