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The following is a short primer on dental benefits, nomenclature, and questions.

Q: Why does my insurance pay less than I was told?
A: There are several reasons that one may receive reimbursement less than expected:
a. The insurance company may base payment on "average" fees or a "table of allowances", and this list may be out of date or not from your area. 
b. Your company may have a limited provider list and your dentist may not be on it. 
c. Your policy may pay for only the least expensive treatment. This may not be the treatment you and your dentist have selected as best for you.
d. Some types of treatment are often covered at lower percentage. An example might be crowns ("caps") at 50% coverage and fillings at 70%.

Q: Why can't I go to any dentist I select?
A: Some employers arrange treatment with a closed group of dentists contract providers -- to lower insurance purchase costs.

Q: Why do my premiums keep going up?
A: Your group may be using more services than were planned or inflation may be causing the costs of all goods and services to increase. Insurance companies raise prices to continue to make a profit.

Q: How should I handle problems with my dental benefits?
A: First, check your benefit booklet. Then go to your company's benefits office or your union representative. You may also wish to contact the Insurance Commissioner's office of your state.

Getting the Most from Your Dental Benefits

a. Read your benefits booklet.

b. Know your options. Be familiar with limitations and exclusions set by the employer's policy. Remember, you and your dentist need to decide the treatment that is best for you no matter what insurance covers.

c. Communicate with your dentist, employer and insurance company. Your benefits office needs to know how your plan is working.

d. Practice good oral hygiene. Good dental health is your responsibility.

e. Use your benefits! Some plans even have improved coverage if you maintain regular visits for observation and care. For instance, with some plans your coverage may go from 80% to 90% to even 100% every year you continue routine visits.

Unscrambling the Language

Insurance language can get quite confusing! Here's an explanation of some of the most-used terms:

UCR: A common way insurance companies use to set maximum benefit levels. The exact definition varies somewhat from company to company.

USUAL: The fee that an individual dentist most frequently charges for a given service. Some insurance companies define this as the lowest fee routinely charged.

CUSTOMARY: Fees set by the insurance company based on what has been charged in a selected area by similar kinds of dentists. The insurance company defines the areas and how often to update the information. As a result these fees may vary greatly.

REASONABLE: Fees adjusted for certain circumstances of treatment. Example: caring for a patient with advanced heart problems and diabetes, or treating a child with behavior problems. NOTE: it is to your advantage to be certain that your dentist's office notes any of these complications when submitting your claims.

PREFERRED PROVIDER ORGANIZATION (PPO): A group of dentists contracting with an insurance company to provide care at reduced fees and with, perhaps, other restrictions. Note that insurance companies generally do not evaluate the quality of care or dentist qualifications to become "preferred."
CAPITATION/PREPAID: Similar to a PPO but participating dental offices receive some payments whether or not enrolled/assigned patients come into the office. Often, patients are required to pay surcharges for certain procedures such as crowns. Usually, these charges are based on a table of payments and are not related to the dentist's fees.

TABLE OF ALLOWANCES (SCHEDULE OF BENEFITS): The employer has purchased a contract that sets specific dollar limits for each covered procedure. These limits may not cover the total cost of treatment. You are responsible for the difference. These allowances may have little to do with average fees (UCR) charged on your area.

Note: some companies pay just a percentage of the amount shown in their table.

CO-PAYMENT: The part of the fee you owe. For the dentist not to collect the co-payment is against the law and the dentist's code of ethics. Don't ask!

PREDETERMINATION: Some contracts require you to send in treatment plans before your treatment starts. The insurance company then tells you what benefits will be paid. Caution: changes in treatment plans may require notifying the insurance again to check your coverage. Some companies set expiration dates on predeterminations. There is legal question whether a claim can be denied if the patient has chosen not to predetermine the coverage.

FREEDOM OF CHOICE: You will receive full plan benefits for treatment provided by any dentist your personal choice. See Closed Panel, below.

LIMITATIONS: Certain procedures may simply not be covered as often as you need. A common example might be a plan that pays for tooth cleaning only twice a year even though the patient requires cleaning every three months. Other plans, for instance, will only pay for new dentures every five years. Limitations may vary depending on the contract purchased. EXCLUSIONS: denies coverage for certain procedures. For instance: cosmetic treatments, bonding, braces, implants and other techniques.

LEAST EXPENSIVE ALTERNATE TREATMENT: The employer has purchased a plan that allows the insurance company to pay for a less costly treatment. The insurance company may call this treatment "adequate." Remember, you and your dentist must decide what is the best treatment for you! This may be the time to appeal decisions to your local dental society.

What Type of Plan Do You Have?

INDEMNITY: Your insurance company pays all or part of specific services. This plan type usually allows patients to choose their own dentist. Limits and copayments are set according to the amount of coverage purchased by your employer or union.

DIRECT REIMBURSEMENT (DR): You choose your own dentist and treatment plan. You then receive and pay for dental treatment. You then submit the receipt to your employer for payment. DR often eliminates paperwork, limitations, restrictions and delays.

DENTAL CARE SERVICE PLAN: An organization of participating dentists who agree to charge eligible patients fees that do not exceed a pre-determined level and who accept other restrictions in providing care.

CLOSED PANEL: The insurance company contracts with a limited number of dentist to provide care for eligible patients. If you seek care at non-participating offices you may receive less or no insurance benefits.

A Quick Check List:
___ a. What types of dental benefits does your employer provide?
___ b. Are there limitations on treatment or exclusions of types of care?
___ c. How are benefits figured? A UCR system? A table of allowances?
___ d. Does your plan require pre-determination of benefits? When? Is this legally binding?
___ e. What is your annual maximum coverage amount? Per person? Per family? Per lifetime?
___ f. Is there a deductible? Per person? Per family? Paid how often?

Your Responsibility

More and more patients are getting help paying for their dental care through dental insurance. Increasingly, dentists are getting concerned that misunderstandings about insurance can undermine a long tradition of trust between patient and dentist. Dental insurance is a contract between your employer and an insurance company.

It is definitely not written by your dentist! Ultimately, you are responsible to the dental office for any fees not paid by your insurance. Sometimes, dentists will ask that you take care of your entire bill and be reimbursed by the insurance company. Sometimes, they will only ask you to cover your co-payment costs. Please feel free to discuss your concerns with your dentists and his or her office staff to avoid misunderstandings.

For more information please click here to contact us or call (973) 553-9486 to setup an appointment.