Smiles by Payet Dentistry – Beautiful Smiles. Lifetime Care

Family, Laser, and Cosmetic Dentistry by Charlotte dentist Dr. Payet.

Dental Insurance: What does it cover and what doesn’t it?

Dental insurance is an interesting issue today, and it’s often a complicated one that confuses many patients.  Heck, sometimes it even confuses us!  Therefore, I’d like to offer a little clarification on what dental insurance is and isn’t, what it covers and what it doesn’t cover, when it’s worth having and when it’s not, and what you can do to make your life and ours a lot easier, smoother, and more trouble-free when it comes to your dental benefits.

  • First and foremost: DENTAL INSURANCE IS NOT LIKE MEDICAL INSURANCE!!!! I really can’t stress this enough.  With medical insurance, you pay your copay, and your insurance pretty much covers everything after that unless you go out of network or it’s something unusual.  With dental insurance, you typically only get a certain amount of benefits per year, usually $1,000 – $1500. If you’re really lucky and have a great employer, it might be as high as $2,000/year.
  • What does “UCR” mean, and is it really what it says? “UCR” stands for “Usual, Customary, and Reasonable” fees.  Here’s the problem that most people don’t understand……every single insurance company determines what THEY think UCR should be, it varies by the ZIP code of your doctor/dentist, and not only will insurance companies NOT tell us or you what their UCR fees are, but they also don’t even reveal how they calculate them. Obviously, this makes it much more difficult for us to accurately estimate what your co-pay will be, and unfortunately, it often means you end up with a remaining bill after insurance pays less than we originally expect.  The GOOD NEWS is that we have recently updated our practice management software to the newest version, and it has some marvelous features that will help us estimate much more accurately as we input more data.  Please be patient with us, though — it is time-consuming to do and will take a little while to have completely set up.
  • In-Network vs. Out-of-Network: There is a big misconception out there that – if you go to an out-of-network dentist (assuming you have a PPO and not a DMO) — you will end up paying a lot more out-of-pocket.   Here’s the thing – that simply is not necessarily true!  Now, sometimes it is, especially on really major kinds of treatments, such as bridges, implants, and the like.  But for check-ups and cleanings, fillings, and sometimes even crowns, there may be no more than a $10-20 difference.  Ask yourself this simple question: if you are really happy and comfortable with your dentist, isn’t it worth a few extra bucks to keep seeing someone you know and trust, rather than pick a dentist just because they’re “in-network,” even if you may not like them but you save a few bucks?
  • My cleanings are covered 100%, Doc!” Sadly, this is no longer true for everyone.  With the current economy, many companies are changing the coverage they offer, and some of those plans don’t even cover 100% of your regular cleaning, EVEN IF you go to an In-network dentist.  Sad, but true.  It is very important that you keep yourself informed of what you plan covers and doesn’t.
  • “But my insurance was SUPPOSED to pay $XXX amount, and you told me wrong!” This is where we are really looking forward to the improvements in our software that should help us calculate the proper amount, but there is an EXTREMELY important fact to remember, which is: we can never give you better than an ESTIMATE of what the insurance will pay.  The insurance company itself will tell you the same thing if you call them.  Doesn’t even matter if you call and give them the ADA procedure code, our fee…..they STILL will only give you an estimate, NOT a guarantee. I know this can be frustrating, and it is for us, too, because we know it’s never fun getting a bill in the mail after you thought you’d paid all you had to pay.
  • The last item for today: please remember that, when it comes down to it, you are responsible for the entire bill.  If your insurance doesn’t pay; if your company quit paying the dues and the coverage lapsed, or any of the other possible reasons insurance doesn’t pay or it pays less than expected, you are responsible for paying your bill.  We bill the insurance as a courtesy to you.

Of course, this doesn’t even get into all the details of all the different insurance plans.  Bear in mind that our software has almost 500 different insurance companies listed, and there are probably close to 1000 different policies.  It is impossible for us to know every detail of every plan, although we sure do our best to find out.  Your best bet, though, is to know your coverage, too.  Ask you Human Resources department to help; they are often a great resource if your insurance company is trying to get out of paying, too.

Yes, dental insurance is complicated. Call us if you have any questions.

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February 19, 2009 - Posted by | Dental Insurance, PPO vs. HMO | , , , , , , , , , ,

1 Comment »

  1. […] Here is a new post at Dental Insurance: What does it cover and what doesn’t it? « Smiles …. […]

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