Dentist Fees and Dental Insurance
We are committed to providing you with the best possible care. If you have dental insurance, we will help you to receive your maximum allowable benefits. In order to do this, we need your assistance and your understanding of our financial policy.
Our policy is a simple one. We have found,over the years, that thorough and meaningful communication before treatment embarks has lead to the least amount of payment problems and to the most satisfied patients.
Basically, we at Sachem Dental Group, expect payment at the time of service unless other arrangements have been made in advance.
Since many patients carry dental insurance that frequently covers only a portion of incurred fees,we encourage patients to establish payment arrangements for the non-insurance portion of their services before treatment is started.
While the filing of all insurance claims is a courtesy we extend to our patients, all charges are ultimately the patient’s responsibility.
Logistics of Filing Dental Claims
At the time of your dental exam, the treating Doctor will discuss a treatment plan designed for your specific dental needs. For those patients with dental insurance, Sachem Dental Group encourages patients to allow us to pre-estimate their proposed treatment with your insurance carrier. This will determine covered benefits and out-of-pocket expenses. Of course, patients have the option to start their treatment without a pre-estimate. In this case, the patient would take full responsibility for treatment costs and of course would be credited any monies eventually received from applicable insurances.
It should be noted that there may be situations where patients have co-pays or co-insurance and in some cases the patient may also be responsible for amounts that exceed their deductible and annual maximums. Finally, Sachem Dental Group expects that by the time a patient’s treatment is complete, that their account be paid in full.
Sachem Dental Group offers various payment plans, some with interest free options. Sachem Dental Group accepts all major credit cards and offers Care Credit payment plan.
When most people think about health insurance, the first thing that comes to mind is medical insurance. This is insurance covering the costs of serious medical conditions, such as cancer or heart disease, or accidents.
Dental Insurance is Different
First, unlike medical disease, which is unpredictable, dental ailments are generally preventable. Therefore, preventive care, including regular checkups and cleanings, is the key to maintaining your oral health.
Second, because the costs relating to dental care are generally lower than medical, the way the insurance works is not the same. Dental insurance is designed to cover a portion of the costs of most procedures. And that amount will vary depending on the carrier you have, and the type of benefit plan you choose.
Finally, it is important to remember that to minimize your personal out-of-pocket costs, regular visits are essential. When problems are diagnosed early, the treatment is always less extensive (and expensive) than when the condition has progressed.
Dental Insurance Plans.
Dental insurance plans have many different features, and it is important to understand them.
Some of the options are:
Company responsible for funding benefits.
Freedom offered in selecting the dentist.
The benefit scale and payment methodology.
Regardless of the dental benefit plan, there are usually three parties involved in the dental insurance process:
A third party whom your employer has contracted for coverage.
There are three types of third parties.
Dental Service Corporations
These not-for-profit organizations negotiate and administer contracts for dental care to individuals or specific groups of patients. Delta Dental Plan and Blue Cross/Blue Shield Plans are examples of this third party type.
These for-profit companies underwrite the financial risk of, and process payment claims for, dental services. Carriers contract with individuals or patient groups to offer a variety of dental benefits packages, often including both fee-for-service and managed care plans.
These companies use their own funds to underwrite the expense of providing dental care to their employees. The company pays for the dental costs of its employees, usually with limitations on services and fixed-dollar allocations.
Pre-determination of Benefits
Some plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator may determine: the patient’s eligibility; the eligibility period; services covered; the patients required co-payment; and the maximum limitation. Some plans require predetermination for treatment exceeding a specified dollar amount. This process is also known as preauthorization, pre-certification, pretreatment review or prior authorization.
Although your dental benefits plan may not be bound to predetermined costs, this mechanism can help you and your dentist plan and budget a treatment plan appropriate to your oral health needs.
Annual Benefits Limitations
Annual Benefits Limitations. To help contain costs, your plan may limit your benefits by number of procedures and/or dollar amount in a given year. In most cases, particularly if you’ve been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much your plan allows, you and your dentist can plan treatment that will minimize your out-of-pocket expenses while maximizing compensation offered by your benefits plan.
Eight Things to Consider When Choosing a Dental Plan
Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company?
If you have a family dentist with whom you are satisfied, consider the effects changing dentists will have on the quality or quantity of care you receive. Because regular visits to the dentist reduce the likelihood of developing serious dental disease, it’s best to have and maintain an established relationship with a dentist you trust.
Who controls treatment decisions – you and your dentist or the dental plan? Many plans require dentists to follow treatment plans that rely on a Least Expensive Alternative Treatment (LEAT) approach. If there are multiple treatment options for a specific condition, the plan will pay for the less expensive treatment option. If you choose a treatment option that may better suit your individual needs and your long-term oral health, you will be responsible for paying the difference in costs. It’s important to know who makes the treatment decisions under you plan. These cost control measures may have an impact on the quality of care you’ll receive.
Does the plan cover diagnostic preventive and emergency services? Is so, to what extent?
Most dental plans provide coverage for selected diagnostic services, preventive care and emergency treatment that are basic for maintaining good oral health. But the extent or frequency of the services covered by some plans may be limited. Depending upon your individual oral health needs, you may be required to pay the dentist directly for a portion of this basic care. Find out how much treatment is allowed in any given year without cost to you, and how much you will have to pay for yourself.Every dental care plan is different. As a basis of comparison, with the very best plans, the following services will often be covered in full, with no deductible or patient co-payment. Normally, however, there will be some co-payment by the patient.
Initial Oral Examination – once per dentist
Recall Examinations – twice per year
Complete x-ray survey – once every three years
Cavity-detecting bite-wing x-rays – once per year
Prophylaxis or teeth cleaning – twice per year
Topical Fluoride treatment – twice per year
Sealants – for those under age 18
What routine corrective treatment is covered by the dental plan? What share of the costs will be yours?
While preventive care lessens the risk of serious dental disease, additional treatment may be required to ensure optimal health. A broad range of treatment can be defined as routine. Most plans cover 70 percent to 80 percent of such treatment. Patients are responsible for remaining costs.
Examples of routine care include:
Restorative care – amalgam and composite resin fillings and stainless steel crowns on primary teeth
Endodontics – treatment of root canals and removal of tooth nerves
Oral Surgery – tooth removal (not including bony impaction) and minor surgical procedures such as tissue biopsy and drainage of minor oral infections.
Periodontics – treatment of uncomplicated periodontal disease including scaling, root planning and management of acute infections or lesions
Prosthodontics – repair and/or relining or reseating of existing dentures and bridges.
What major dental care is covered by the plan? What percentage of these costs will you be required to pay?
Since dental benefits encourage you to get preventive care, which often eliminates the need for major dental work, most plans are not generous when it comes to paying for major dental work, most plans cover less than 50 percent of the cost of major treatment. Most plans limit the benefits – both in number of procedures and dollar amount – that are covered in a given year. Be aware of these restrictions when choosing your plan and as you and your dentist develop treatment best suited for you.
Major dental care includes:
Restorative care – gold restorations and individual crowns
Oral Surgery – removal of impacted teeth and complex oral surgery procedures
Periodontics – treatment of complicated periodontal disease requiring surgery involving bones, underlying tissues or bone grafts
Orthodontics – treatment including retainers, braces and/or diagnostic materials
Dental Implants – either surgical placement or restoration
Prosthodontics – fixed bridges, partial dentures and removable or fixed dentures
Will the plan allow referrals to specialists?
Will my dentist and I be able to choose the specialist? Some plans limit referrals to specialists. Your dentist may be required to refer you to a limited selection of specialists who have contracted with the plan’s third party. You also may be required to get permission from the plan administrator before being referred to a specialist. Is you choose a plan with these limitations, make sure qualified specialists are available in your area. Look for a plan with a broad selection of different types of specialists. If you have children, you may prefer a plan that allows a pediatric dentist to be your child’s primary care dentist. Since specialized treatment is generally more costly than routine care, some plans discourage the use of specialists. While many general practitioners are qualified to perform some specialized services, complex procedures often require the skills of a dentist with special training. Discuss the options with your dentist before deciding who is best qualified to deliver treatment.
Can you see the dentist when you need to, and schedule appointment times convenient for you?
Dentists participating in closed panel or capitation plans may have select hours to see plan patients. They may schedule appointments for these patients on given days, or at specified hours of the day, restricting your access. Some dentist’s fees for seeing you on weekends or during emergencies are high than those the plan allows. You may be required to pay additional costs yourself. If you select these types of plans, have a clear understanding of your dentist’s policies as well as the plan’s dentist-to-patient ratio. It’s the best way to insure your access to care is not unduly restricted and that you are not surprised by higher fees the plan does not cover.
Will the plan provide benefits to patients who may also be covered by another dental plan?
It is not unusual to be eligible for dual benefits. You may be covered under you company’s plan as well as under that of your spouse’s employer. In analyzing your options, make sure to look for a plan that allows coordination of benefits.
Getting the most from your plan
To take full advantage of your dental benefits plan, visit the dentist regularly and get the preventative care that will keep your mouth healthy. Follow the treatment plan you and your dentist have developed. Do your dental homework – brush and floss regularly and maintain a regular schedule of oral examinations and teeth cleanings.
Glossary of Terms
UCR. A widely used method, which may vary from company to company, for determining benefit reimbursement levels. The initials simply mean:
Usual. The fee that an individual dentist most frequently charges for a given dental service.
Customary. A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area.
Reasonable. A fee which is justifiable considering special circumstances of the particular care rendered.
Table of Allowances. Assigns a specific dollar to each dental procedure.
Pre-determination. After the treatment plan is decided upon by the patient and the dentist, the insurance company reports back on what portion of the treatment plan will be covered.
Freedom of choice. Allows the patient to choose any dentist. Coverage with this feature allows you to receive full benefits for treatment provided by any dentist of your choice.
Limitations. Limits the benefits for procedures or the number of times a procedure will be covered.
Exclusions. Denies benefit coverage for certain procedures.
Least Expensive Alternate Treatment. The insurance company’s contractual arrangement with the policyholder allows the insurance company to substitute a less expensive, but in the insurance company’s opinion, professionally adequate service.
Q Why does my dental insurance pay only 50 percent of the charges when my policy says it will pay 80 percent?
A There are several possibilities.
If your benefits are based on capital UCR calculation, it might indicate that the UCR data is out of date or not specific to your local area.
If you belong to a PPO, your full benefits will be paid only if you seek care from one of the contracting dentists.
If your benefits are calculated using a Table of Allowances, the table might be out of date or set at an unrealistically low amount.
If your policy provides for the least expensive treatment, you will be reimbursed the stated percentage based on the cost, even if you choose alternate treatment.
Q Why can’t I go to any dentist?
A Many employers will contract with a closed panel or preferred provider program to contain the costs of insuring employees. As a result, your dental benefits might only be available by seeking care from a dentist who has contracted with that company.
Q Why do my premiums keep going up?
A Dental insurance premiums are in part based on the anticipated claims experience of your group. If that group experiences an unexpected high utilization of major dental services, the premiums will go up. Insurance company administrative costs and premium taxes also contribute to the cost of dental coverage.
Q Is my dentist overcharging when my insurance company reimburses me for only part of the dental fees?
A Insurance companies pay claims in various ways. Many base reimbursements on UCR rates. However, even the UCR allowances may vary from company to company. While these reimbursements usually are based on what the majority of dentists in your area charge, sometimes the figures used to calculate benefits may be out of date or not specific to your locations. And, if the company uses a Table of Allowances, benefits assigned to specific dental treatment may not relate to actual costs.
Our office participates with most major insurance plans.
Most insurance are accepted as full or partial payment.
Contact the appropriate office if you have any questions about your individual dental insurance carrier or benefits.