Dental insurance is one of the most beneficial yet misunderstood components of dental treatment. The following explanation will attempt to clarify common misconceptions.
Indemnity Dental Insurance is a contract between the employer, the patient, and the insurance carrier. There is no contract with the dentist. Limits of coverage vary from company to company, and sometimes even within the same company. Limits of coverage have absolutely nothing to do with the level of service provided by the dentist or with the fee charged for these services. The insurance carrier pays according to the stipulations of their contract, and the patient pays the difference to the dentist.
PPO or "Preferred Provider" Insurance does include a contract with the dentist to accept a reduced fee from the contracting insurance comany. The insurance company will only provide coverage if you are treated by a dentist on their list. There is no selection process of listed dentists other than their willingness to sign a contract with the company. The insurance company may further limit its payments to LEAT or "least expensive alternative treatment." This does not mean that you must accept minimal treatment, it just means that the insurance company is required to pay only what they would have paid for the least expensive treatment and that you are required to pay the difference. Some PPO plans include a rider that allows you to "go out of network." Again, this is established when your employer negotiates its contract with the insurance carrier.
Many companies establish an arbitrary ceiling, or "UCR" (usual and customary) above which they stop their reimbursement. This level of coverage is determined by the contract negotiated by your employer and not by the fees charged by your dentist. There is always an annual limit beyond which your dental insurance company will make no further payment. Generally this limit is in the range of $1000 to $1500 and has remained unchanged for the past 40 years!
We will make every effort to assist you in filing your dental insurance claim. As a courtesy to you, our patient, we will prepare and submit your insurance claim forms to your primary carrier. We will be happy to provide an estimate of expected insurance reimbursement and the anticipated patient balance due. Your share will be due at the time of your dental treatment. Should our estimate of patient share be too high, a prompt refund will be made to you when we receive payment from your insurance carrier. Should our estimate of pateint share be too low, the remaining balance will be due from you when we receive payment from your insurance carrier. Should we receive no payment within sixty days of claim submission, the entire outstanding balance will become the sole responsibility of the patient.
Should you have further questions concerning your dental insurance coverage, we will be happy to discuss them with you. If necessary, payment plans are available to help you budget your dental treatment.