The Insurance Utilization Process
Our office remains dedicated to providing optimal care for every patient and working with you to achieve that goal. We pride ourselves on helping you in every way possible to provide the quality of care to which you have become accustomed.
Let's be transparent:
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.
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.
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.
If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. By law, your insurance company is required to pay each claim within 30 days of receipt. We file all insurance electronically so your insurance company will receive each claim within days of the treatment. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. Many insurance companies try to control the amount of dentistry you receive by requiring authorization for procedures in advance. Our office will do everything possible to help you maximize the insurance benefits to which you are entitled. We recognize that the authorization process is often time-consuming and frustrating.
We participate with:
- Aetna PPO
- Delta Dental PPO
We work with all other insurance companies that are part of a PPO plan, as an out-of-network provider. These plans need to be verified before your upcoming appointment to know your estimated out-of-pocket expense.
Good out-of-network plans are:
- Cigna PPO
- Guardian PPO
- Metlife PPO
- United Health Care PPO
Cash patients a first-time appointment which includes Prophy, Fluoride and Exams will need to be paid upfront.
We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. At no time do we guarantee what your insurance will or will not do with each claim. We also can not be responsible for any errors in filing your insurance.
As part of our commitment to outstanding customer service, we will:
- Work with you to achieve the maximum
reimbursement to which you are entitled Complete and submit dental insurance forms to your insurance company Provide you accurate and timely information about any fees not covered by your dental insurance