Insurance Policy and Options
During the past decade, medical and dental benefit plans have become an integral part of health care planning for many families. Medical and dental benefit plans are made available to employees and their family members through companies, unions and associations, and vary considerably from one plan to the next.
The range of benefits depends solely on what the plan purchaser wishes to offer employees or members. Plan coverage may range from 100% to no coverage at all for a given procedure, although most plans fall within the 50-80% range. Some plans exclude certain procedures, while others provide full range of benefits.
Some plans base the benefit amount on a chart or schedule of fees arbitrarily developed by the third party payers. Therefore, you may receive a lower amount of reimbursement than your plan leads you to believe. For example, if your plan states that it will pay 80% of the cost of dental treatment, it may actually mean 80% of the fee as determined by the insurance company, not the fee charged.
In order to avoid any confusion or misunderstanding, we would like to explain both the principles of our practice and the type of service and care we provide to our patients:
Our fees are based on the overhead involved in our practice, the treatment plan selected, and the time it takes us to provide you with the necessary dental care. We do not compromise our recommended treatment in order to accommodate a medical or dental plan’s maximum benefits which may be less than optimal. This would be unfair to you. However, we will certainly help you prioritize treatment and determine what problems should be solved first, to help you maximize your insurance benefits. We are also more than happy to discuss a treatment plan’s advantages and disadvantages with you. In this way you, not the third party payer, are involved in the decision making process. Again, the type of treatment you receive from us is based on your needs and our professional judgment, not whether you are covered by a dental benefits plan.
If your dental benefits plan requires a “predetermination” or “prior authorization” we will submit a treatment plan for review by the third party payer. However, please remember that the financial obligation for medical or dental treatment is between you and this office. The third party payer is responsible to you, not our office.
Should you receive a communication from the third party payer suggesting that our fee is over and above the reasonable and customary rate for the services provided to you, please do not accept this as fact without first discussing the matter with us. The third party payer’s fee data may be extremely out of date, or simply incorrect. They may also base their fee schedule on a national average, rather than that of our area.
After speaking with us, if you believe that the dental benefits provided by your plan are inadequate, you may want to discuss this matter with your employer, union or association, so that appropriate alternatives can be investigated. We will be happy to provide any information or written materials you may need to do this.
We will help you in every way in filing your claims, handling insurance queries, writing letters, processing follow up requests for further information, resubmitting lost claims, etc. No question is too small for you to ask, whether it is about your treatment plan, benefits or statement. Stop in or call any time you have a question. We are here to help you not only achieve and maintain your oral health, but to comfortably deal with any financial concerns as well.
Why Doesn’t My Insurance Pay for This?
Employers offer medical and dental benefits to help employees pay for a portion of the cost of their dental care. Dental plans are designed to share in the cost of your dental care, not to completely pay for those costs. Almost all dental benefit plans are the result of a contract between the plan sponsor (usually an employer or a union) and the third-party payer (usually an insurance company). The amount your plan pays is determined by the agreement negotiated by your employer with the insurer. Your dental coverage is determined not by your dental needs — but by how much your employer contributes to the plan.
Key terms typically used to describe the features of a dental plan may include the following:
UCR (Usual, Customary and Reasonable)
Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the plan for eligible services. The plan pays an established percentage of the dentist’s fee or pays the plan sponsor’s “customary” or” reasonable” fee limit, whichever is less. Although these limits are called “customary,” they may or may not reflect the fees that area dentists charge. Exceeding the plan’s customary fee, however, does not mean your dentist has overcharged for the procedure.
Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in wide fluctuation. In addition, insurance companies are not required to disclose how they determine” usual, customary and reasonable” charges.
Most dental programs have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period, usually the plan year. The plan purchaser/employer makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company. The patient is usually responsible for paying costs above the annual maximum. Your employer may want to research plans that offer higher annual maximums when assessing how to better meet the needs of employees.
The plan may want you to choose dental care from a list of its preferred providers. This is a term that often is applied to dentists who have a contract with the dental benefit plan.
Whether or not you choose to receive dental care from this defined group can affect the level of reimbursement.
Just like medical insurance, a dental plan may not cover conditions that existed before the patient enrolled in the plan. This includes plans that have a “missing tooth” exclusion. Benefits will not be paid for replacing a tooth that was missing prior to the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary.
A dental plan may not cover certain procedures or preventive treatment. This does not mean that these treatments are unnecessary. Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions. Your dentist can help you decide what type of treatment is best for you.
Coordination of Benefits and Non-duplication of Benefits
Coordination of benefits (COB) is a method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges.
Non-duplication of benefits is a term used to describe one of the ways the secondary carrier may calculate its portion of the payment if a patient is covered by two benefit plans. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid.
Even though you may have two or more dental benefit plans in place, there is no guarantee that any of the plans will pay for your services. Please consult with your own plan for further details regarding coordination of benefits and non-duplication of benefits.
Not Dentally Necessary
The plan provides benefits for those services and materials that it considers to be dentally necessary and meet generally accepted standards of care. Based on the information your dentist submits, the service may not appear to meet plan criteria and no benefit may be allowed. This does not mean that the services were not necessary. You or your dentist can appeal the benefit decision by submitting relevant information. The claim, along with the submitted information, should be reviewed by the plans dental consultant.
Cost Control Measures
To keep the premium costs down, insurance carriers will incorporate cost control measures into the plan design. By incorporating cost control measures during the claims adjudication process, many times benefits are reduced or not paid at all. Some of the more common cost control measures are:
Bundling —This is the systematic combining of distinct dental procedures by third-party payers that result in a reduced benefit for the patient/beneficiary.
Down coding —This is the practice of third-party payers in which the procedure code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements.
Least Expensive Alternative Treatment —the dental plan may only allow benefits for the least expensive treatment for a condition. As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit overages. In many instances, the least expensive alternative is not always the best option. You should consult with your dentist on the best treatment option for you.
Explanation of Benefits (EOB)
An EOB is a written statement to a beneficiary, from a third party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan. In those instances where the plan makes partial payment directly to the dentist, the remaining portion for which the patient is responsible should be prominently noted in the EOB. Any difference between the fee charged and the benefit paid may be due to limitations in the dental plan contract. Typical information reported on an EOB includes: 1) The treatment reported on the submitted claim by ADA procedure code numbers and nomenclature; and 2) The ADA procedure code numbers and nomenclature on which benefits were determined.