Insurance Misconceptions

These misconceptions are promulgated by the insurance companies and dentists alike. To begin with, dental insurance is not really insurance at all. Insurance covers monetary loss. Dental insurance is a monetary benefit negotiated by your employer to help you pay for your oral health needs. These benefits are a result of negotiations between your employer and a dental insurance company. They never (or very rarely ever) cover the fee your dentist charges for a given service. Dental insurance payments are capped , and in many instances these caps have not changed since the 1960's. Try to think of dental insurance as a true "benefit" in that it can help you pay for part of your treatment.

Conflict arises when patients believe a dental expense is covered at a certain rate only to find out that they still owe the dentist money when the time comes to pay. One classic example arises with the question often heard-

"My dental insurance said it pays 100% for my dental cleanings; what do you mean I still owe you money?!"

In this classic example, the patient has looked at his EOB (estimation of benefits) form that that tells you what they paid, and sees that the fee charged by the dentist exeeds the "Usual Customary and Reasonable" (UCR) fee. The trouble is that the UCR fee is whatever has been negotiated between your employer and the insurance company, and is directly dependent upon the premium he pays for your benefit. That is why the coverage can vary even between the employees of a same company. Dental fees vary from region to region in the country for the same reasons that fuel, rent and groceries do.

Other misconceptions

"You're the doctor; surely you can help persuade the insurance company to pay you more easily than they pay us."

As the doctor, we help you file your insurance request, and supply the insurance company with everything we think they need to process your claim in a timely fashion. Problems arise because different insurance companies and the products they offer often require different types of supporting documentation. We think we know what your insurance companies need to process a claim but on a daily basis these requirements seem to change. These changes require resubmitting your claim and further delays. Also be advised that insurance companies routinely deny the reception of a claim even when sent via registered and certified mail. We have no other power to expedite or to gain approval of the claim than, in good faith, try to explain your treatment, and supply the necessary supporting documentation (such as x-rays) and other records that might be needed.

In reality, insurance companies are more responsive to your contact with them as you are the contract holder, not us. Patients usually have the right to request copies of any UCR fee schedules from their insurance provider, but dentists do not. Any advice that you may require in the pursuing of a denied claim will be gladly offered by us.

An example where the denial of a specific code directly affects the payment of treatment of a dental disease follows.

One code that is commonly denied by insurance companies is Gross Debridement. This is a code used by dentists in the initial treatment of a patient with heavy deposits of calculus and tartar that inhibit the practitioner from properly diagnosing periodontal disease. It superficially removes enough of the accretions on tooth structure so we can accurately assess the bone loss that this disease causes. Many patients are upset by the denial of payment for this treatment and fail to realize that its use tags them for future periodontal treatment acceptance within the internal workings of an insurance company. If it is necessary for you to have this treatment, it may save you money in the long run.

Again we strive to help you in filing your insurance claims, but be advised our influence over what procedures and coverage your company may provide is very limited. Try not to let your insurance benefits dictate the course of treatment you seek for your dental care. There is only one of you. There are many items out there you could buy instead. See our Why We Are Different page to decide if we are the dentists for you.