Our office accepts any insurance plan as long as it is a Preferred Provider Organization (PPO) plan. However, we are considered an “Out of Network” provider. Your insurance will still provide benefits, but will pay at what is usual, customary, or reasonable (UCR). (Continue reading below for more UCR information). We do not accept any HMO or DMO policies. If you have an HMO or DMO dental plan, please contact your insurance company for a list of participating dentists.
Navigating insurance benefits, coinsurance provisions, deductibles, conditions and co-pays can be really confusing. After receiving all your insurance information, we can estimate your financial portion of the dental service fee and ensure you receive the maximum benefits to which you are entitled. If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. We file all insurance electronically, so your insurance company will receive each claim within days of the treatment. You are responsible for any amount that insurance does not cover.
PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. Consequently, you are ultimately responsible financially for the services rendered. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not pay on each claim. We also can not be responsible for any errors in filing your insurance. Once again, we file claims as a courtesy to you.
MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment.
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.
Insurance companies set their own fee 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.
Statements such as the one given above make 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.
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.
Dental insurance is meant to be a financial aid to dental care. Many people assume that their insurance pays 90%-100% of all dental fees. Unfortunately, this is not true. Most plans only pay between 50%-80% of the average total fee. Some plans 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.
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.