Insurance is confusing even for dental professionals, so you can only imagine how confusing it can get for patients. Many patients will ask questions about dental insurance, and this can be an intimidating thing to navigate given the complexity of the topic. To help you out, here are some of the most common questions that you may be asked by a patient regarding insurance, as well as a great example of how to answer them.
It is always advised to explain the limitations of dental plans to patients.
Often they do not understand the difference between medical and dental insurance, and educating them helps to prevent confusion and conflict in the event that the required dental treatment is not covered.
Why doesn’t my insurance cover all the costs of my dental treatment?
Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.
How does my insurance carrier come up with its allowed payments?
Many carriers refer to their allowed payments as UCR, which stands for usual, customary, and reasonable. However, usual, customary, and reasonable do not really mean exactly what it seems to mean. UCR is a listing of payments for all covered procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and where you are located in your city and state. Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire. UCR payments could be accurately called negotiated payments.
Since most payments are negotiated, does this mean that there is always a balance left for me to pay?
Typically there is always a portion that is not covered by your benefit plan.
I received an Explanation of Benefits from my insurance carrier that says my dental bill exceeded the usual and customary. Does this mean that my dentist is charging more than he or she should?
It does not mean that your dentist is charging too much. Remember that what insurance carriers call UCR is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. It is usually much less than what any dentist in your area might actually charge for a dental procedure.
Why is there an annual maximum on my benefits?
Maximums limit what a carrier has to cover each year. Amazingly, despite the fact that costs have steadily increased, annual maximum levels for dental care have not changed since the 1960s.
Why do some benefit plans require me to select a dentist from a list?
Usually, a dentist on the list has agreed to a contract with the benefit plan. These contracts have restrictions and requirements. If you choose a dentist on the list, you typically pay less toward your dental care than if you choose a dentist not on the list. Insurance companies do not add dentists to their plans based on their experience, quality of care, attention to detail, or level of customer service provided in the practice.
Insurance companies simply add dentists who agreed to accept their fees.
You should choose your dentist based on the care you will receive and not on insurance plan recommendations.
Why does my dental plan only pay toward the least expensive alternative treatment?
To save money. Your dentist may recommend a crown, with your insurance only offering a benefit toward a filling. This does not mean you have to accept the filling. You should do what is best for your dental health.
Why won’t my insurance pay anything toward some procedures, such as X-rays, cleanings, and gum treatments?
Your plan contract specifies how many of certain types of procedures it will consider annually. It limits the number of X-rays, cleanings, etc. covered because these are the types of treatments that many people have frequently. You can choose to do those procedures regardless of insurance coverage.
What should I do if my insurance does not pay for treatment I think should be covered?
Because your insurance coverage is between you, your employer, and the insurance carrier, your dentist does not have the power to make your plan pay. If your insurance does not pay, you are responsible for the total cost of treatment. Sometimes a plan may pay if patients send in a claim for themselves. The Employee Benefits Coordinator at your place of employment may be able to help. Patients may also lodge complaints with your state’s Insurance Commission.
What if my spouse has insurance?
Dental plans used to work together. However, many times you will get little or no coverage from a second plan. Consider any extra benefit as an unexpected gift.
Why can you only estimate my coverage?
Dentists deal with thousands of plans and hundreds of types of treatments each year. Most carriers refuse to release the details of their plans. They change policies and reimbursements constantly and with our notice.
ALWAYS remember to remind the patient that it is a mistake to let benefits be your sole consideration when you determine what you want to do about your dental condition.