The Insurance utilization process
We file all services electronically so your dental benefit company will receive each claim within days of the treatment. We will follow up with them and work on your behalf to maximize the services you and your employer have chosen. We do not have access to the exact package and it can vary within a company.
Are you “in Network”?
We are not in network with specific benefits companies. This means that we have not signed a contract with them. Contracts can limit the services we are allowed to provide and in some cases they will not pay if we do not honor the contract. The benefit company can modify the terms at any time which is why a Pre- Authorization or Pre- Determination will always have a disclaimer.
“This is not an authorization, nor a guarantee of eligibility, benefits, or payment.”
Will I have to pay more to see an out of network provider?
The insurance company recommends that you see you a contracted provider so that they can control their costs associated with your treatment. This is done by putting a limitation on the type of service or the materials that can be used. Generally the costs of these services or materials are less resulting in a lower bill for the benefit company to pay.
What is the advantage to my family in seeing an “out of network provider”?
As an unrestricted provider the treatment plan is decided on by you and the Doctor with the best interests of your child at the forefront. The benefit company and your employer do not get a seat at the table when deciding what is best for your child and family.
Examples of Benefit Companies our patients have are:
Aetna PPO
Assurant PPO
Cigna PPO
Delta Dental PPO
Blue Cross/Blue Shield
Guardian PPO
Metlife PPO
Principal Plan
United Health Care PPO
You do not have to have Dental Benefits to be seen at Open Sesame !
Our Smile Assurance Membership works similar to an Employer provided benefit plan. We also have discounts for same day payments.
Fact 1
NO insurance pays 100% of ALL procedures
Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage or the type of contract your employer has set up with the insurance company.
Fact 2
Benefits are not determined by our office
You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, 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 company. A statement such as this 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 can be very misleading and simply is not accurate.
Insurance companies set their own schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR Fee. Frequently this data can be three to five years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit.
Unfortunately, insurance companies imply that your dentist is “overcharging” rather than say that they are “underpaying” or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.
Fact 3
Deductibles & co-insurance must be considered
When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less.
MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment.