Dental insurance is a highly complex area that creates confusion for many dental patients. The complexity of dental insurance and the lack of sufficient information provided by some insurance companies make it impossible for some patients to properly understand their benefits. Even more confusing is trying to learn how to properly work with your dental insurance to help achieve the highest level of benefits to which you are entitled.
Dental insurance is a contract between an employer or an individual, and a dental insurance company. The benefits you are entitled to receive are based on the terms of the contract negotiated between your employer’s representative and the dental insurance company’s representative, and not your dentist. Most dental insurance policies allow benefits for specific dental services that have been negotiated and pre-arranged by an employer and the insurance company, consequently some services are not covered. The selection of non-covered services is not based on what you need or want, but is based strictly on the contract and guidelines set forth by the insurance company, usually to help them cut costs and save money. In most cases, dental insurance has not been established to pay for all dental costs, but only to help pay for a portion of the total cost of treatment needed.
The term UCR stands for Usual, Customary and Reasonable. The term UCR was created by insurance companies in order to justify their fees for different procedures done by a dental office. Every insurance company has a different list for what they consider to be UCR, and they pay benefits based on these different fee lists. How an insurance company views a fee is directly influenced by the cost of the premium that is paid to them by an employer. The higher the premium, the higher the fee payable. Likewise, the lower the premium, the lower the fee allowed. Please understand that the fees that the insurance company bases payment on are not necessarily a reflection of the quality of care that you receive. In most cases, insurance companies will pay for treatment that will get the patient taken care of with the least amount of cost on their part. Likewise, insurance companies will sometimes change the billing of a dental procedure to reflect treatment different than what was actually done. This is called an “alternate benefits clause." Often the types of services that are changed are fillings, crowns and office visits.
It is our policy to help you in every way possible to know and understand the benefits that are available to you through your insurance company. We can obtain basic benefit information for you with a phone call and can give you an estimate for services at that time. However, with the ever-changing insurance industry as a whole, there may be exclusions or limitations that may not be disclosed to us when we call. It is always beneficial if the patient can bring to the office at the time of your appointment, a copy of your insurance booklet to aid us in helping you further understanding your policy.
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.
In most cases, we can begin treatment prior to receiving an authorization from the dental insurance company. However, patients need to understand that in the event the dental insurance company refuses to pay for treatment, you are responsible for all fees. Naturally, we always provide you with the full fees in advance so that you know the exact cost of treatment. Like you, we recognize that the authorization process is often time consuming and unnecessary.
Dental insurance companies typically do not cover some types of dental services. These include cosmetic dentistry, implants, occlusion or bite redesign, and some other services. Although these are important dental services that can greatly enhance the quality of life of our patients, dental insurance companies do not feel that they should have to pay for these services. That is why these services are rarely included in contracts with your employer.
Any time you have a question about your dental insurance, please feel free to ask us. We recognize that dental insurance becomes more complex and more difficult to understand every day. That is often due to the quest by dental insurance companies to reduce costs through continual changes. Keep in mind that the dental insurance companies are not concerned about covering for optimal dental care, but provide coverage for only a limited number of basic services.
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 any way and in continuing to provide the quality of care to which you have become accustomed.
Please let us know if you have any questions as it will be our pleasure to help you.