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Dental Insurance




 

Understanding Dental Insurance

We would like to stress that our relationship is with you and not with your insurance carrier. As a courtesy service, we will bill your insurance for you and will send any necessary letters and pre-determinations. If your insurance carrier will send payment directly to our office, and if we can verify your coverage, we will bill your insurance and await payment. You will be asked to pay your estimated co-pay and deductible. You are responsible for any balance remaining after the insurance company has paid the claim. If we do not receive payment from your insurance company within six weeks, for any reason, full payment becomes your responsibility and is due at that time.

Visit our Frequently Asked Questions section for more information.

The following are some basic terms that will greatly improve your understanding of how your dental insurance works.


"Accepting" Insurance Annual Limit Co-Pay
Deductible Fee Schedule Lifetime Maximum
Participating Insurance Pre-determination Renewal Date

 

 
 
Dansville Dental Professionals, LLP, 25 Red Jacket Street, Dansville, NY 14437  |   (585) 335-2201
Copyright 2016 Dansville Dental Professionals, LLP. All rights reserved.

"Accepting" Insurance

At Dansville Dental Professionals, we accept most dental insurances. By this, we mean that if your dental insurance will send payment directly to our office, we will accept your insurance as payment, and only request that you pay your deductible and co-pay at the time of service. We will handle processing the insurance forms for you, and we will bill your insurance and wait for insurance reimbursement.

Participating Insurance

Most insurance plans offer contracts to dentists. The dentists agree to charge a reduced fee set by the insurance company in exchange for the insurance company encouraging patients to use that dentist. There are several very obvious problems with this concept of making a "deal" with the dentist to cut fees in exchange for more patients. It limits your options in choice of dentist and encourages you to use dentists who are possibly in need of patients and who may be willing to cut corners on quality or service so that they can afford to provide the service for much less money and still remain profitable. For these reasons and many others, we limit our "participation" to only a handful of companies whom we have carefully screened and selected based upon the coverage provided and the terms of the agreements.

Co-Pay

This is the amount that the insurance company requires you to pay for any given procedure. For example, if your insurance covers fillings at 80%, and you have a $100 filling done. Your co-pay would be 20% of $100 or $20. (Some offices will waive the co-pay – accepting the insurance payment as payment in full so that the patient pays nothing – this is insurance fraud and is illegal). Some insurances apply the deductible to preventative care, others do not.

Deductible

This is an annual amount that your insurance requires you to pay before the insurance goes into effect. For example, if your deductible is $50. You must pay the first $50 each year yourself before the insurance will cover anything. Some insurance plans have a deductible per family member, others have a single deductible per family.

Fee Schedule

UCR – The fee schedule (prices) set by the insurance company. UCR is an abbreviation for "usual customary rate". Interestingly enough, the UCR varies greatly from company to company and has no connection with the real world. Caution is in order here. For example, if an insurance company tells you that they pay 100% of something, what they usually mean is that they pay 100% of THEIR fee schedule. Their fee schedule is anything they want it to be. So, even if the insurance states that they pay 100% of a given procedure, you may still have a co-pay due. For example, if you have a cleaning and our fee is $40, and your insurance company pays 100% of their fee schedule of $35, you will still have a co-pay of $5.

Pre-determination

Most insurance companies request a "prior" or "pre-determination of benefits" for any major work. In other words, even if the treatment to be provided is a covered procedure, the insurance carrier requires that documentation and x-rays be sent to them for review prior to providing the service. This is a great inconvenience to the patient and a great money saver for the insurance company. By stalling treatment, some patients do not follow through, and it also allows the insurance to retain their funds longer, generating more interest income. Many times, they "lose" predeterminations or request additional information, further delaying treatment for the patient. The end result is that needed and wanted treatment that should be paid by the insurance is typically delayed several weeks. However, if the predetermination is not done, or is not current, the insurance company has grounds for not paying the claim, even if it is covered under the terms of the policy. Another caution here is annual limits. Even if you have a pre-determination showing coverage for a given procedure, the insurance will not cover that procedure if you have exceeded your annual limit.

Annual Limit

This is the maximal amount of insurance dollars the company will pay per family member per year regardless of the coverage percentages listed. For example, if you need $1200.00 worth of dental care, and the insurance provides 100% coverage for that work, but you have an annual limit of $1000, they will only pay $1000 in any given year. And, they don't pay that $1000 until after you have paid your $50 deductible. Typical limits are $1000 or $1500 per calendar year. Even though premiums go up every year, and dental fees go up every year, these annual insurance limits have not increased since the 1960's. So, each year, the buying power and value of your insurance policy actually decreases. We will monitor your annual limit for you and do our best to inform you of where you stand. However, we cannot be aware of work that you have had done in other offices (including specialists that we referred you to) , and cannot really monitor every insurance for every patient. You will need to keep an eye on your annual limits yourself – which should show on every insurance statement you receive.

Lifetime Maximum

Some insurance policies have now added a life time limit to coverage. Once you use up your life time limit, they no longer provide coverage. This is totally unfair to people who have insurance coverage as a retirement benefit or employment benefit and are counting on their insurance for security against dental expenses.

Renewal Date

The annual date at which your annual limit resets.

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