Most patients have a hard time understanding their dental benefits. There are as many different plans as there are contracts, and dental insurance is not the same as medical insurance. In fact, it’s not really “insurance” at all.
A patient’s employer selects the plan and is ultimately responsible for the design of the contract. Each contract specifies what procedures are covered. Even if a procedure is dentally necessary, it may not be covered. This doesn’t mean it isn’t needed, of course, it simply means it’s not “covered.”
Your plan is a legal contract between you and your insurance carrier. The provider is not privy to that contract and is considered a third party. Regardless of having insurance you are ultimately responsible for the entire balance on your account. At Advanced Dental Center, we work diligently to provide you with the most comprehensive care and work hard to maximize your benefits. The truth is that dental insurance rarely pays for 100% of all services. Below are some of the most frequently asked questions about Dental Insurance:
What is dental insurance?
Maintaining good oral health and preventing dental problems before they happen is important to staying healthy. Dental insurance helps you manage the cost of dental care so you can maintain your overall good health. Most dental insurance covers preventive care, which includes regular checkups by your dentist, and may also cover care for cavities, implants or getting a tooth knocked out.
How does dental insurance work? What are my costs?
If you’ve had health insurance, you’re going to be familiar with how a dental plan works.
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You pay a premium, a certain amount monthly, to buy the plan.
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Your deductible is what you have to pay out-of-pocket for services covered by your plan before the insurance company pays.
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Your plan may include copays, a fixed cost you pay for a certain service, like an X-ray.
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Coinsurance refers to the percentage you pay of covered expenses after you meet your deductible. So if your coinsurance for a filling is 30%, and the cost for that service in-network is $100, you would pay $30 of that. The insurance company would pay for the rest of your covered expenses up to your annual maximum.
How do I understand my Explanation of Benefits (EOB)?
Your Explanation of Benefits or EOB is a great place to find out information on your plan. The EOB identifies the benefits, the amount your insurance carrier is willing to pay towards the services and what is not a covered benefit. The statement includes the following information: UCR, copayment amount/patient portion, remaining benefits, deductible, and the paid benefits. If you ever have questions about your EOB, we recommend that you contact your insurance carrier directly.
What does In-Network Mean?
An in-network dentist (preferred provider) has signed a contract with your insurance company that sets agreed upon fees for all procedures. This usually results in you, the patient, receiving a reduction in cost of services of anywhere from 20-40% depending on the procedure.
* Accepting your insurance is not the same as being in-network with your insurance.
I have Dental Insurance and it says your office is in-network. Do I have to pay for my cleanings, exam or X-rays?
Generally no. Because we are in-network, most all of the insurance plans we have seen to date tend to cover exams, cleaning and X-rays at 100%, so most of our insurance-based patients don’t pay anything when they show up for annual cleanings and exams. However, this usually does not apply for people who have periodontitis (because the cleanings are different). But note that it will reduce your annual maximum. For example, the cleaning fee is $80. We will claim your dental insurance for $80. You do not need to pay anything to your dentist, but if your annual maximum was $1000, then after the insurance carrier accepts the assignment, it will be $920.
What is “Allowed Amount”?
“Allowed Amount” is a term used by insurance carriers to describe a Fee Schedule. Basically, the allowed amount is a set fee that the insurance carrier will pay towards procedures. This amount is typically very low. Some insurance carriers pay 100% of this set fee and others pay a percentage of this set fee. The patient will be expected to cover the amount that the insurance carrier does not cover and this could be the entire balance. Typically the insurance carrier will not disclose the actual allowed amount with the provider. The insurance representative will state that the patient needs to refer to their benefits booklet.
Example: The insurance carrier states that they will cover a surgical extraction at 100%. On the date of the procedure we tell the patient that our office will bill the insurance carrier first, as the representative stated that they will consider paying for 100% of the services and whatever portion they do not cover, we will request from the patient. The insurance carrier pays $14 tow
How do you verify my benefits?
Upon receipt of your complete insurance information our dental team in Norwalk, CT will call your insurance carrier directly. We ask your insurance carrier about your maximum, deductible, and a list of codes that are commonly used in our practice, along with any frequencies and limitations that may apply to some of these codes. We prefer to speak to a live person. However, some insurance carriers do not allow out-of-network providers to talk to representatives and in this case we request a fax of your benefits. The fax typically does not have the specific information that we prefer, and due to the lack of information provided we may ask you to pay for 100% of services performed in our practice. We use the information that we gather from your insurance carrier to provide you with an itemized breakdown of what we estimate your carrier to cover and what we are estimating to collect from you on the date that services are rendered. The plan information that the insurance carrier gives out is never a guarantee of payment and thus every patient is responsible for the entire balance on his or her account.
Why doesn’t my insurance cover all the costs of my dental treatment?
Our dentists in Norwalk, CT diagnose and provide treatment based on their professional judgment. Some employers or insurance plans exclude coverage for necessary treatment as a way to reduce their costs. Your plan may not include this particular treatment or procedure, but our dentists, Dr. Tal Yossefi and Dr. Elad Yossefi, may deem the treatment to be necessary. We recommend that you do not let your insurance carrier or coverage dictate your care. Most plans cover only a part of the total fee for dental services.
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.
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. This should be stressed to the patient. Any amount reduces the out-of-pocket expense for 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. 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.
How long does it take my insurance carrier to pay the claim?
The time for a dental insurance carrier to process an insurance claim varies. At least 38 states have enacted laws requiring dental insurance carriers to pay claims within a timely period (ranging generally from 15 to 60 days).
What does “Accepting Assignment” mean?
“Accepting Assignment” is a term used by the insurance carrier and means the insurance carrier will send the payment to the provider. Some insurance carriers do not accept assignments with non-contacted or Out-Of-Network providers and will mail the insurance payment to the patient. If your insurance carrier fails to accept the assignment then you will be responsible for the entire balance on your account.
Maintaining good oral health is a key part of staying healthy. It’s important that you have regular dental care. Dental insurance helps manage the costs of preventive care and also helps lower costs in the case of unexpected events, like a broken tooth or a cavity.
Please do not hesitate to contact us if you still have any questions regarding dental insurance!