As a Patient, understanding your dental benefits can be difficult. There are many different plans and different contracts between the insurance company and the patient’s employer. Dental insurance is not the same as medical insurance. Dental insurance has a maximum amount that they pay up until usually a range of $1000-$2500 yearly and they put a $50 deductible on major dental work. Medical insurance pays on everything after you meet your yearly deductible and even before you meet your deductible medical insurance pays on preventative visits and medications. So, in fact, dental insurance is not really insurance at all.
WHY DOESN’T MY DENTAL INSURANCE COVER ALL THE COST OF MY DENTAL TREATMENT?
Dental insurance isn’t really insurance at all. It is NOT a payment to cover a loss. It is actually a BENEFIT provided by employers to help employees cover the cost of routine dental treatment. An employer will buy a plan based on the amount of benefit and the cost of the premium for the employer and employee. Most plans will cover only part of the total fee for dental services.
WHY ARE EXAMS & CLEANINGS, AND OTHER PROCEDURES NOT 100% COVERED LIKE MY PLAN SAYS?
The insurance company typically allows a certain percentage as payment for a procedure. It is NOT always what the dentist will charge. For example, if a cleaning is covered at 100%, an insurance company may pay $60 as payment for a cleaning, but the dental office charges $80. This leaves $20 the patient is responsible for because the insurance company places a UCR (Usual/customary/reasonable) fee on every procedure. A UCR fee is set by each insurance company and every insurance company and every plan within that company has a different UCR fee.
WHERE DO THE ALLOWED AMOUNTS (UCR ) COME FROM?
UCR fees are actually a list of payments negotiated between the insurance company and the patients employer. These negotiated fees are based on the cost of the premium to your employer. In other words, the lower the allowed amount the lower the premium paid by your employer. Just because you as a patient have Delta Dental insurance and are employed by Company X, and your friend also has Delta Dental insurance but is employed by Company Y you will NOT have the same insurance. Every aspect of those two separate plans will be different from fees to maximums based on what your employer decides they want to pay for a premium as a benefit to you.
IS THE DENTIST CHARGING MORE THAN HE/SHE IS SUPPOSED TO?
This question is usually in response to an EOB (explanation of benefits) from the insurance company. Remember that amount paid for treatment is the negotiated fee between the insurance carrier and the employer. That amount is applied to the actual fee. Typically, this negotiated fee is much lower than what dentists in your area are charging. It does not mean the dentist is overcharging. Every insurance has different negotiated fees between every employer.
WHY DOESN’T MY DENTIST PARTICIPATE IN MY NETWORK?
Many dentists are uncomfortable with the restrictions that are placed on them by “NETWORK” plans. Dentists want to build a relationship with the patient to treat them how they need to be treated and NOT how the insurance company says, We as dentists should not treat someone because it is a cheaper option. The insurance company does not have the best interest of the patient in mind. The insurance company tries to save/make money any way possible. “As a dentist, I am here to recommend and deliver treatment based on my best diagnosis and prognonsis and then to educate my patients based on that. I never want to let an insurance company dictate the treatment of the patient and what I know is best for my patient’s dental health”