The Purpose of Dental Insurance
Dental insurance is a contract between an employer and an insurance company. It obligates the insurance company to pay you back for a percentage of the costs of any covered dental service. The terms of those contracts are widely varied, and are often dependant upon the cost of the plan. In many instances the plans pay a higher percentage on preventive care, a lower percentage on restorative care, and the lowest percentage on the things that cost the most. Therefore, dental insurance is a way to help you pay a portion of your dental costs, and it is not intended to be a pay-all. Regardless of what the insurance company pays, the patient is responsible for paying their entire dental bill.
As a courtesy, we are happy to file insurance claims for you. With so many companies and policies being issued, there is no way we can keep up with what each one pays. Therefore, it is your responsibility to know what your dental insurance covers. Please be aware of this: The insurance company has no contractual obligation to your dental office. Your dentist does work for you in exchange for a fee. You are responsible for full payment of your bill regardless of the status of your insurance claim.
Common Problems with Dental Insurance
There is often a misconception that once you have dental insurance you are covered for any and all expenses you incur at a dental office. But in many instances only certain things are covered, and the coverage that you do get goes into effect incrementally. An example might be a plan that covers preventive and diagnostic services immediately, restorative services after six months, then makes you wait a full year before covering crowns, bridges, or dentures. Of course, those waiting periods have nothing to do with when you need care, only when they will pay for it. You should make yourself aware of any waiting periods that apply so you don’t get any financial surprises.
Dental Insurance plans have annual maximum payouts that are allowed. This is exactly the opposite of major medical insurance plans that pay all charges over a set amount known as your stop loss. Unfortunately, the amount that they pay out per year has not increased much over the past 20 years, while the costs of dental services have gone up substantially. If you need anything more than the normal preventive care, a filling or two, and a single crown, you’ll probably exceed your annual maximum.
Just because you have exceeded the annual maximum for your plan does not mean that you should put off recommended dental care. Delays can jeopardize a patient’s health, which is a bad choice. Some patients have mistakenly assumed that annual maximums are intended to gauge how much dentistry a person should have in a year. The fact is they are intended to assure the profitability of the insurance company—nothing more. If you find yourself in need of extensive dental work within a year, you will likely have to fund the care on your own.
Some dental insurance plans pay on a fixed fee schedule rather than a percentage of the cost incurred. That fee may be the entire amount charged or very little of the amount charged. Our fee is not affected by whether they pay much or little. Be aware that fee schedule plans often have low benefits to the patient, and leave you paying more out of your own pocket.
Sometimes insurance companies limit amounts they pay for dental procedures and claim that the charges exceed the usual, customary and reasonable charges for your area. But how are those amounts determined? There is no policing agency to make sure that UCR limitations are fairly calculated. There is no mandated reporting of the fees charged by area dentists, so the only way a company knows fees is by collecting data from the claims they receive. It is not scientific; it’s always based on old data, and is always based on averages.
Although we strive to keep fees affordable, there may be times that your insurance company says a fee we charge is above average. They could be right, because we don’t do average work here. We continually strive for excellence. It is impossible to consistently do above average work and charge average fees. But we always give excellent value by keeping fees reasonable, and using the best materials and techniques available. We stand behind our work, and use the highest possible standards when placing restorations for our patients.
Some insurance plans exclude specific procedures. These exclusions may have nothing to do with whether or not the procedure is needed or appropriate. In many instances the excluded procedures are simply a matter of keeping the cost of the policy low for the employer. Insurance companies have to make the price of their policies competitive in order to sell them. Then they have to keep their payout low enough to make a profit. Cosmetic and experimental procedures are almost always excluded, as are dental implants. Other commonly excluded services include Nitrous Oxide Sedation, Inlays and Onlays, use of our Laser, Fluoride treatments, and tooth colored fillings. Sometimes what gets excluded is the
best treatment for your specific condition. That puts you, the patient, in the difficult position of choosing between the best care with no coverage and the inferior care allowed by your insurance plan with coverage.
There are often a variety of ways to treat dental conditions. As you might imagine, some are far superior to others. If your insurance plan only pays for the cheapest possible treatment, you may be faced with having to pay for the better care without the benefit of insurance. There are many times that we have decided not to perform procedures we consider inferior or substandard. Although we are capable of performing the procedure, we know they are not in the patient’s best interest. In that case you might have to find alternate means of financing your dental care.
There are times when insurance plans will not pay to fix any problem that existed before you were covered on that plan. It may be the replacement of a tooth that was lost prior to coverage, or treatment of a condition that was chronically building over time such as wear on your teeth. Unfortunately those long-standing problems are often the ones most needing treatment. We will recommend going ahead with treatment even though insurance will not pay for the treatment.
Many times we find that insurance companies return claims—even ones that are filled out correctly with all needed information—and ask for some minor amount of extra information. In our opinion this is nothing more than an excuse to delay payment of the claim. Our office only files insurance claims as a courtesy to our patients—we have no obligation to do so. We allow our patients to pay the amount we guess that the policy will not cover. It is the responsibility of the patient to pay their entire dental bill if the insurance company fails to make payment for over 45 days, no matter what the reason. Our office is committed to providing you and the insurance company with all reasonable information in order to help them process your claim and get you the insurance benefits you deserve, but we cannot accept responsibility
for the fact that some insurance companies pay slowly.
We realize that you have a choice to make about where you get your dental care, and we work hard to assure it will be worthwhile for you to go “out of network”, if you have one of these more restrictive policies. For years we have maintained this policy, and although some patients have opted to go to a participating dentist, we have been gratified by the fact that many (if not most) have returned to our office because they thought the service was superior here than at other offices.
We file normal dental insurance claims daily, and allow our patients to pay only the estimated patient portion at the time of service. This amount is only an estimated portion, and should not ever be construed as the final amount due. If there is a difference in the amount we estimate the insurance company will pay and what they actually pay we send a refund or a bill for the appropriate amount. Our computer tracks reimbursement amounts for each insurance plan, so it is usually pretty accurate.
Patients who have dental insurance plans that will not pay “out of network” providers are expected to pay
for their dental care at the time of service unless prior financial arrangements are made. Reimbursements are usually lower for an “out of network” provider.
If you don’t like the coverage you have, ask your employer to consider changing carriers or getting a better policy from the same carrier. If enough people express the interest in a better dental insurance plan, maybe you’ll get what you request.
There is a chance that your employer is paying all they can afford for the coverage you are receiving. If that is the case, we can be grateful for the help we get, and look for other alternatives to cover expenses that are not covered by insurance. Ask us what expenses you can expect, and we can help you develop a dental savings plan.
Some dental care is reimbursable by medical insurance. Examples include dental services rendered because of an automobile or other accident, or because of damage to teeth as a result of a medical condition. Although these are legitimate reasons to file dental claims under medical insurance, we have had very poor success at getting reimbursed for those services in a timely manner. Therefore we cannot accept assignment of benefit for services covered under medical insurance. We will not file medical claims for you, but we will be glad to assist you in filing your own medical claim. We will provide you with a list of all procedures for which we have charged you, the associated description of the service, and the clinical reason for the procedure. With this information and a completed form you should be able to file your
Our primary concern is your dental health. We believe that you deserve a fabulous and functional smile, so making your dental treatment affordable is a concern for us. We offer our patients a variety of payment options to fit all budgets.
We gladly accept Bank Cards, Visa, MasterCard, Discover, and American Express. By leaving your credit card on file with our office, we will charge the amount due for services rendered on the day that services are rendered. You will not be required to stop and pay after each treatment.
In order to offer the best dental services to our patients our office reserves individual appointment times for every patient. Often, our practitioner’s spend significant time preparing for your scheduled appointment. Should something occur that requires you to break your scheduled appointment, we ask that you give a minimum of 48 hours notice for any appointment changes or cancellations, yet earlier notification is greatly appreciated. This gives other patients the opportunity to be scheduled in your place, and allows our practitioner’s time to adjust their schedules. We also ask that you arrive on time for your scheduled appointments.
Emergency Care FAQ
People risk breaking their teeth or otherwise injuring their mouths while eating, playing, exercising, and participating in other seemingly harmless activities. It’s important to understand what to do in case of a dental emergency so that your tooth can be repaired when you are able to see a dentist.
Dental emergencies can occur when your tooth breaks, cracks, becomes loosened, or is knocked out completely. Sometimes dental crowns come off of teeth. Lips, gums, or cheeks can be cut.
Dental emergencies can be avoided by taking simple precautions, such as wearing a mouthguard during sports activities to prevent teeth from breaking or being knocked out, and avoiding hard foods that may crack or break your teeth – whether you have your natural teeth or you wear dentures. Oral injuries often are painful and should be treated by a dentisit as soon as possible.
If your tooth is knocked out, immediately call a dentist for an emergency appointment. It is important to see your dentist wihin an hour of when your tooth is knocked out for the best chance of the tooth surviving the trauma. Handle the tooth by the crown (the top), not by the root (the pointed part on the bottom). Touching the root of the tooth can damage cells that are necessary to reattach the tooth to the bone. Gently rinse the tooth in water to remove dirt. Do not scrub the tooth! Place the clean tooth in your mouth between the cheek and gum to keep it moist. It is important not to let the tooth dry out. If it is not possible to store the tooth in the mouth, wrap the tooth in a clean cloth or gauze and immerse it in milk or saline solution (the solution used for contacts). If a baby tooth is knocked out, the tooth should not be replanted. The patient should be seen as soon as possible to make sure there are no remaining pieces of the tooth.
If your tooth is loosened and pushed out of position, call your dentist right away for an
emergency appointment. In the meantime, attempt to reposition it to its normal alignment using very light finger pressure – but don’t force it!
There are different types of tooth fractures. Chipped teeth are minor fractures. Moderate fractures include damage to the enamel, tissue, and/or pulp. Severe fractures usually mean that a tooth has been traumatized to the point that it cannot be recovered.
If you fracture a tooth, rinse your mouth with warm water and use an ice pack or cold compress to reduce swelling. Take ibuprofen or aspirin, for pain. Your dentist can smooth out minor fractures with a sandpaper disc. Alternatively, restorative procedures may be needed to fix the tooth.
If you wear dentures and a tooth breaks or chips, wear your spare dentures until you can visit your dentist. If you do not have a spare set or cannot get to the dentist’s office soon, use cyanoacrylate (heavy-duty, quick-drying “super” glue) to glue the tooth or the piece of the tooth back into place. Remember – this is only a temporary measure until your dentist can properly repair your tooth and should only be used for dentures! Never attempt to glue a natural tooth or part of a natural tooth back into place!
Injuries inside the mouth include tears or cuts, puncture woulds, and lacerations to the cheek, lips, or tongue. The wound should be cleaned immediately with warm water, and the injured person should be taken directly to an oral surgeon for emergency care. If you can’t get to an oral surgeon, the patient should be taken to the hospital.
Bleeding from a tongue laceration can be reduced by pulling the tongue forward and using gauze to place pressure on the wound.