Dental Insurance 101

This article will hopefully give patients with and without insurance a better understanding of what dental insurance is, and is not. We will answer some of the most common questions we get about dental insurance.

I thought my dental insurance would cover this, why did the dental office send me this bill?

We are experts at helping you maximize your benefits, but understand that it is our experience that some dental benefit providers are making changes that may or may not be communicated to you. We strive to be upfront, and considerate with all our patients, but we have no control over what insurance companies ultimately cover or don’t cover and at what rate. Even if we verify and pre determine a benefit before the procedure is complete.

Dental insurance is increasing in premium and decreasing in benefits, not to mention rules changing with no notice to subscribers or to us the providers.

It’s a constant struggle to keep up with dental insurance companies and their new rules, outsourcing to foreign support to foreign countries and we know that if we’re frustrated, surely you are as well.

I need some dental work, What dental insurance plan should I get?

Let’s gets something straight, dental insurance isn’t really ‘insurance’ at all. It is actually a spending account with ever changing restrictions that expires every year if you don’t use it.

Most employers usually choose a plan based on the amount of benefit and how much the premium costs. Most benefit plans only cover between $1,000 (an average plan) and $2,000-$2,500 (an excellent plan) of dental costs per person per year.

In 1970 dental insurance annual benefit was $1000 an now its average $1500. Adjusted for inflation, the annual benefit would need to be $6229 per year. Rarely do plans cover more than $2500.

Our primary goal is to educate you about your dental health and help you achieve your goals. Unfortunately, that is not the goal of your dental insurance.

We are participating providers with many dental insurance companies. In some cases, the same dental insurance company will have multiple fee schedules that your employer can choose from.

The lower the reimbursement rate to the dental provider, the lower your employer’s monthly fee, but there are fewer dentists that will accept these fees. (This is often the difference between a ‘Gold’ and ‘Platinum’ plan.)

What is the benefit of an in network provider?

Dental insurance is different from medical insurance in that in most cases your dental insurance will still pay an out-of-network provider (unless they have specifically stated that they will not), where medical insurance usually pays little or nothing if you see a doctor or go to a hospital that is not contracted with your insurance company. Dental insurance companies will still pay, but only at the rate that they would pay an in-network provider. Because the out-of-network provider has not entered into an agreement to discount their fees, the patient is then responsible for the difference in what the insurance paid and the dentist’s fees.

In most instances, the patient will pay less out of pocket to an in network provider than an out of network provider. Despite what the out of network provider may tell you this does not equate to better care, better quality materials etc. The quality of dentistry is not regulated by dental insurance companies; it’s regulated by the state dental board.

In our office we treat every patient with the same high quality standard of care regardless of their insurance plan or how much we are paid for a procedure. But I cannot speak for what other offices do, nor can they speak for anyone else but themselves.

You told you were in network and now I find out you are not in network?

Sometimes we aren’t sure who we are contracted with. Bigger insurance companies buy out smaller insurance companies. The worst part is that nobody is notified of these changes! The best way for you (and us!) to find out if we are contracted with your insurance is to call them directly. However, we can call the insurance company and talk to three different people and two will say in network and one will say out of network. A classic case of the left hand does not know what the right hand is doing.

What is the difference between an allowed fee and a contracted fee schedule?

There is another, more confusing way that insurance companies are getting out of paying 100% for your regular cleanings. Well, some companies are now also coming up with what they call an ‘allowed fee’. This ‘allowed fee’ is different (read: lower) from the fee schedule that was agreed upon with the provider. And, guess what? The insurance company will happily pay 100% of the ‘allowed’ fee, and leave the patient paying the difference between their ‘allowed fee’ and the contracted fee schedule. Pretty tricky, right?

Benefit plans are often difficult to understand. If any part of your plan is not clear to you, or if you are unsure as to what your plan actually does and does not cover, contact your employee benefits coordinator or the human resource department where you work for more information. This could end up saving you a lot of unpleasant surprises down the road.

Why was my filling downgraded?

To save money, some dental benefits downgrade common procedures. For example, we only do composite (or white) fillings in our office. Composite fillings cost more than amalgam (silver) fillings. Many insurance companies choose to only pay for a filling at the amalgam rate even though a composite filling was actually placed, because it’s a less expensive alternative. So let’s say a composite filling was placed and charged at $125. This insurance company chooses to downgrade their benefit and only cover that filling at the amalgam rate of $100. If this company covers fillings at 80%, they would pay $80 which would leave the patient responsibility at $45 which is the difference in the amalgam filling charge and insurance payment PLUS the difference in the amalgam and composite filling. Not all insurance companies do this, but it’s nice to be aware of it if yours does.

Does my insurance cover that?

Sometimes, dental insurance companies won’t pay anything toward some procedures. This is usually because they limit the frequency that a procedure can be billed. This happens most frequently on cleanings, fluoride treatments, and x-rays. There are more limitations popping up all the time, however. A new one we’ve just come across in our office is an insurance company only paying for two fillings per year. With this plan, if your child has four cavities that need to be restored you will end up paying 100% of two of the fillings because they will only pay for two, no exceptions. This is something to be aware of and ask while shopping for dental insurance.

Can you bill my medical insurance?

Many medical insurance plans now have an embedded dental benefit, but it’s usually not as great as it seems. Often, preventative pediatric dental benefits that are included in your medical insurance are considered covered, but they are applied to your deductible so you end up paying for your child’s visit to the dentist anyway. That’s not usually what you expect when you hear that dental benefits are included, because we’re all so used to preventative care being covered with no cost to the patient. Just be aware of this if it’s the case for you.

What is a waiting period?

Most insurance companies have a waiting period for any restorations. This can be anywhere from 90 days to 1 year. This means that until the waiting period is up, anything done beyond a simple exam and cleaning may not have any benefit and can be left 100% up to the patient.

What do you do when your dental insurance company didn’t pay for treatment that you expected to be covered?

First of all, we must emphasize that as health care providers, our relationship is with you, not your insurance company. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. Any amount the insurance does not pay will be your responsibility. We always do our best to inform you of what your portion should be after insurance, but it is difficult to be exactly correct 100% of the time. Often, if our estimate is wrong it’s because your plan benefits have changed from the last time we billed your insurance, and neither of us was informed of this change. If you expected your insurance company to pay us differently than they did, may we kindly suggest that you CALL YOUR INSURANCE COMPANY.

The natural reaction is to call our office because the bill came from us, but to be honest, that is what your insurance company is hoping for. Once your insurance company comes back with their payment, an EOB or Explanation of Benefits comes with it. In the EOB it is listed exactly what the patient portion is to be, and that is what is sent on to our patients. This amount is determined by your insurance company to be your financial responsibility, not us.

What is a missing tooth clause?

This is similar to the preexisting condition exclusion in Obama care, but not exactly. Some insurance plans have a missing tooth clause that means if you had a missing tooth before you started on the plan, the replacement of that tooth or teeth will be at your own expense.

I went to a dentist and he did not charge me my copay. Can you not charge me the Copay?

Just as we are bound contractually to accept what they pay us, you are bound contractually by them to pay what they have decided is your portion. If either party goes back on that contract, it could be considered insurance fraud which means big trouble for us, and possibly a cancellation of your dental policy for you. Call your insurance company! Ask them why their benefits are no longer what you expected them to be, why you weren’t informed, and why your premiums still went up this year! You are their customer and they need to hear it from you when you expected more out of them. We’re always happy to help from our end as much as we can, but dental insurance companies must be held responsible for changes to the benefits they provide.

This article is based on option and experience and is accurate to the best of our knowledge as of the date of writing.

For more information on your insurance benefits and how that will help you with your dental needs, call our office at 703-433-0234 in Sterling, VA