Understanding Your Dental Insurance

Some of you out there reading this right now are fortunate enough to have dental insurance provided either by your employer or by a private plan that you pay for privately. If you do have insurance I’m sure you’ve come across a situation in the past where you’ve had to either ask your insurance company a question or ask your dental provider a question. Many times the answers are complicated, misleading or just hard to understand. I want to go over some of the more common scenarios that pop up in my clinic constantly in the hopes to educate you on what your insurance will and won’t cover as well as why your provider does the things they do.

One of the biggest complaints most people have about their insurance is that they have to pay their dental provider in full and the insurance company will then reimburse them(normally within a few days to a week or two at the most). Most people ask “why can’t my insurance company just send you the money”? Here’s the reason why probably about 95% or higher of offices only take payment up front: The provider is at great risk of committing insurance fraud. Take this scenario for example:

I bill your insurance company for $100. You and I have arranged that the consignment(that’s what it’s called when payment is sent to a provider) would come to me, the provider. I get a cheque in the mail for $99; your insurance company has paid 99% of the claim. Most people would just say “Don’t worry about the $1”. Here’s what happens when it comes to your insurance company though… If I don’t collect that $1 I’ve committed insurance fraud. I’ve told the insurance company that the service I provided costs $100 and they paid me accordingly for that fee. If I accept only the $99 they sent to me what I’ve essentially said is “The fee is really $99, but I’m trying to get $100 from the insurance company”.

When I explain this to people many of them will say “Just bill me for $99 then”. It’ not that simple. In my example I had said that the insurance company paid out 99% of the claim sending a cheque for $99 for the $100 submitted. If I submit for $99 they are going to pay out $98. I still end up with $1 that the insurance company has not paid and I have told them the fee is $99. We go back to the exact same problem of “The fee is really $98, but I’m trying to get $99 from the insurance company”.

This is the reason almost all offices will have the patient pay up front and have the cheque go back to the patient. We simply cannot risk loosing our license to practice because we were trying to be nice and give you a break on the fee but inadvertently committed insurance fraud in the process. Billing the patient up front is the easiest and safest way to protect ourselves from insurance fraud as well as the patient by ensuring that treatments that were not performed do not end up being billed to your insurance company. Trust me… if you’re paying up front you will notice if you have to pay for a service that you don’t think you received. If you just get a statement from your insurance company(because the cheque was sent to your provider and not you) with a bunch of procedure codes and the amount of money paid out it will most likely go unnoticed by you if a additional treatment was accidentally, or intentionally, charged when it shouldn’t have been.

Another issue many people have with their insurance is understanding what they are covered for. Take this for example: You need a new upper denture. You call your insurance company to try and find out what is covered for a new denture and they tell you “Sir/Madame, you have $200 available in your plan for the year and you are covered 50% for your denture”. Most people hang up the phone thinking that they have $100 to put towards their teeth. Here’s how it really goes:

You visit your Denturist and they say that it’s going to cost $100 for your denture. Your Denturist sends a pre-authorization and you receive a answer that your insurance will pay $47 towards your denture. What? You called and found out that you had $100 coverage! Here’s the reality… The fee for the denture is $100 and your insurance company will reimburse 50% of this fee not the total amount that is available in your plan each year. That still doesn’t work out to $47 you’re probably thinking. This is because insurance companies rarely follow current fee guides. I’ve found that on average insurance companies are going off a fee guide that is two years old(I’ve seen insurance companies using fee guides from as far back as 17 years ago). This means that when your insurance company gets the claim they look at the $100 submitted, they then adjust the cost of the denture at $100 to what the fees were two years ago which ends up being $94. They then cover 50% of the $94 thus reimbursing you $47. The denture that you once thought wasn’t going to cost you a cent has now cost you $53. You’re not alone if you find this confusing. We work with insurance each and every day and this is second nature to us. For the person with coverage who uses it once a year or once every few years it definitely can be very confusing/frustrating.

If you ever have any questions about your coverage for a procedure ask your Denturist or one of their staff for help. We can guide you through the whole process and help you understand what all of the procedure codes, dollar amounts and reasons for adjustment/denial of your claim means.

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