As a service to our patients, we will submit your insurance claim to your primary insurance company. Our office will provide yourinsurance company with all the information necessary to help you receive your maximum benefit. However, it is your responsibility to know your insurance coverage and the benefit limits of your particular policy.
There is not any direct relationship between our office and your insurance company. Your insurance benefits are determined by thetype of plan chosen by you and/or your employer. As a result, we have no control over the terms of your insurance, the methods of reimbursement, or the determination of your insurance benefits. We will file your insurance, accept the assignment of benefits, and help estimate what your insurance will pay. You will be responsible for any portion of services NOT covered by your dental insurance at the time services are rendered. These fees include deductibles, co‐pay, or certain procedures not covered by your insurance company.
We must emphasize that as a health care provider our relationship is with you and not your dental insurance company. Your dentalinsurance is a contract between your employer and the insurance company. Most plans routinely pay between 50‐ 75% of the average total fee for a covered procedure. This percentage is determined by how much your employer has paid for coverage.
Some insurance carriers will not allow for reimbursement directly to our office. In such instances, you will be responsible forthe entire cost of each visit at the time services are rendered, and the insurance company will send the reimbursement check directly to you. We will electronically file the claim for you to expedite your reimbursement.
Please be aware that the parent bringing the child to our office is legally responsible for payment of all charges.
Fact 1 - NO INSURANCE PAYS 100% OF ALL PROCEDURES
Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage or the type of contract your employer has set up with the insurance company.
Fact 2 - BENEFITS ARE NOT DETERMINED BY OUR OFFICE
You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist's actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist's fee has exceeded the usual, customary, or reasonable fee ("UCR") used by the company.
A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate.
Insurance companies set their own schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the "allowable" UCR Fee. Frequently this data can be three to five years old and these "allowable" fees are set by the insurance company so they can make a net 20%-30% profit.
Unfortunately, insurance companies imply that your dentist is "overcharging" rather than say that they are "underpaying" or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.
Fact 3 - DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED
When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less.Back to Top