Your dental plan is a form of compensation provided by your employer. You can expect the carrier to reimburse you for a portion of your dental visit fee. That portion that is billed is determined by the contract established between your employer and the insurance company. Most employers provide differing coverage plans which dictate your office visit premiums. The higher the premium paid by your company, the more generous the reimbursement.
Although we are not a party to the contractual fee schedule with your insurance company, we do want to help you receive the maximum reimbursement to which you are entitled. As a convenience to you we will help you process your claims in order for you to receive this maximum benefit. We will also gladly provide dental x-rays and a written diagnostic report should your insurance company have any questions about the services provided.
At all times, you can be confident that we will always provide you with our best services without regard to the limitations imposed by your insurance coverage. To do otherwise would violate our contract with you — a contract we feel morally obligated to honor.
-Dr. Samuel Cress, DDS
“Why doesn’t my insurance cover all the costs of my dental treatment?”
Dental insurance isn’t really insurance at all. It is not a payment to cover a loss. It is actually a benefit provided by employers to help employees cover the cost of routine dental treatment. An employer will buy a plan (one of many offered) based on the amount of the benefit and the cost of the premium for the company or the employee. Most plans cover only a part of the total fee for dental services.
“Why aren’t my exams and cleaning, among other procedures, 100% covered like my plan says?”
The insurance company typically allows 100% as payment for the procedure. It isn’t always what the dentist may charge. An insurance company may allow $60 as payment for an exam, but the office fee is $80. This leaves $20 that the patient is responsible for.
“Where do the allowed payments come from?”
Most insurance companies call these payments “UCR,” which stands for usual, customary, and reasonable. But these don’t mean what they sound like. They are actually a list of payments negotiated by the employer and insurance company. The amounts are related to the cost of the premium. In other words, the lower the allowed amount, the lower the premium paid by the employer, or whoever is providing the plan.
“What good is my insurance if I always have a balance?”
Even if the fee is not fully “covered,” at least it pays part of it. Any amount reduces the out-of-pocket expense for you the patient. Something is better than nothing!
“Is the dentist charging more than he/she is supposed to?”
This question is usually in response to a patient receiving an EOB (explanation of benefits) from the insurance company. Remember that the amount paid for treatment is the negotiated fee between the insurance carrier and the employer or provider not the dentists. That amount is applied to the actual fee. Typically, this negotiated fee is much lower than what dentists in your area are charging. It does not mean the dentist is overcharging.
“Why did my insurance company change the treatment to something less expensive?”
Again, this question typically follows a patient receiving an EOB, and the answer is very similar to the previous one. The benefits are negotiated and many times will provide only for less expensive procedures.
Obviously, if a tooth needs a crown, but a filling is all that’s covered, it does not mean that the dentist should do a filling. At least some benefit is paid, and that will be applied to the fee for the recommended treatment. It is the responsibility of the dentist to provide the best treatment. It is the insurance company’s responsibility to save (make) money.
“Why doesn’t my dentist participate in my network?”
Many dentists are uncomfortable with the restrictions that are placed on them by “network” plans. Most dentists do not participate in any of them because it affects their relationship with patients. In other words, patients should trust their doctor—not the insurance company. You and your doctor should make the best decisions for your dental health.
“Can I do anything if my insurance doesn’t cover the treatment I need?”
The coverage is between the patient, the employer, and the insurance carrier. The dentist has no power to make the carrier pay for recommended treatment. There can be some intervention on the part of the dentist, but it is limited at best. The patient simply must be responsible for the total cost of treatment. Patients might be able to file complaints with the state insurance board or commission if there is a legitimate reason.
The bottom line is this: I need to recommend and deliver treatment based my experience and expertise and on the best diagnosis and prognosis. Please do not let a third party, someone who has very little interest in you, dictate your dental health.
Dr. Samuel Cress accepts all dental insurance plans.