Facts about dental insurance

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The following statements are solely those of this office and are derived from the experiences we have had with dental insurance companies and our patients that have had coverage.

Dental insurance is not at all like your medical insurance. They are totally different. Don’t even try to compare them. And, in 99% of the cases, medical insurance does not pay for any type of dental service. Some phases of periodontal therapy may be covered by your dental insurance but it depends on the type of insurance plan that you have. Some plans state that they will cover “up to 80% or 100%” but do not clearly specify their plan’s fee schedule, allowance, annual maximum or limitations. The amount of coverage insurance companies pay ranges from $1000 to $1500 per year and certainly has not kept pace with inflation. In 1959, when dental insurance started, there was a yearly maximum payment of around $1000. There has been no significant increase in the yearly maximum payment since 1959! However, there has been a significant increase in premiums. Had dental benefits kept pace with inflation in relation to the premiums charged yearly dental benefits should be around $6000 today! Dental benefit plans rarely pay for the entire amount of dental care. They only supplement the amount of money that you have to pay for your treatment.


Should your periodontal examination reveal that you need treatment – a list of needed procedure codes and fees is sent to your insurance carrier for what is called a “pretreatment estimate.”With some insurance companies the information is filed electronically; hence, they have the information immediately. Yet, in most cases, it can take up to six weeks for them to send us the estimate back to us. Why so long – ask them!
You may receive communication from your insurance carrier stating that the fee is “over and above the usual and customary” rate. Remember that insurance companies base the amount of benefits on a schedule of fees “arbitrarily” developed by them. For example, if your plan states that it will pay 80% it means that it will pay 80% of the fee established by them and not 80% of the actual fee. It is our experience, that in the final analysis, most companies cover only 40 to 50% of the actual fee! It is commonly discussed in all dental circles that according to the dental insurance industry no dental office seems to be in line with the insurance company’s “usual and customary fees!” This is a standard statement used by all insurance companies. What they are really saying is that they do not want to pay “the going rate” for the dental service provided. How insurance companies arbitrarily determine the amount of benefit is still a mystery to us since they will not reveal this information. It is assumed that their fee schedule has to do more with the company profits than anything else.
It should be pointed out that insurance companies make no fee allowances for the fact that your periodontal therapy is performed by a “dental specialist” with years of extra training and experience. The fees paid by insurance companies are based on general dental fees. Some plans exclude certain types of services and newer procedures. As you are aware technology changes fast in this day and age and insurance companies lag far behind in allowing for this. Our fees are based on the overhead involved, the treatment plan selected and the customary fees charged by the majority of periodontal offices with our training and experience.
We realize that your insurance company leads you to believe that they will pay 80% and you will only have to pay 20% of the fee for your treatment. In actuality, we are aware that the insurance usually covers only 40-50% of the fee. Because of this, we ask that you put down 50% before we begin treatment and any adjustments will be made when your pre-treatment estimate comes in. We will be happy to discuss your treatment plan’s advantages with you and involve you in deciding your dental future rather than letting your insurance company dictate your treatment options. We only have your best interest and dental health in mind!
If there is a balance on your account you will receive a bill each month from this office whether or not you have an insurance claim pending. This is done automatically by our computer program. Many times the insurance company, using delay tactics, does not pay the claim for months. Since this office uses standard business procedures your account will incur interest at the rate of 1 ½ % per month on any unpaid balance over 30 days. You could pay the bill in full to avoid interest charges. When we receive payment from your insurance company we immediately credit your account if you have a balance and refund any amount due you. We have no contract with any dental insurance company. You have the policy - not this office. If you received a bill from this office it means that your insurance company has not sent in your payment. Before calling us – call your insurance company and get ready to hear some of the excuses mentioned in the upcoming section on Delay of Payment.

Be aware that insurance companies will do any number of things to delay payment! They may say that A. They never received the information from our office. B. They do not have enough information. C. They want more information. D. The incorrect dental code was used and any other reason they can find to delay the claim.

We use the proper insurance codes for the procedure performed and we send the information as soon as possible. We do not delay sending this information. When your insurance carrier states that they do not have enough information, this is simply a delay tactic. Many times they ask for the same information over and over again claiming that they never received the information. In the past in we have submitted claims for patients 2 and 3 times. We can no longer do this!
When an insurance company refuses to pay for a procedure that is, almost without doubt, the end of it! Patients ask us to write letters to the insurance company. In over 30 years of practice we have never seen an insurance company reverse its decision not to pay or to increase the amount of payment.
The type of treatment you need and receive is based upon Dr. Rabalais’ professional judgement not on whether you are covered by an insurance plan. If you believe that the dental benefits provided by your plan are inadequate or you have some of the problems stated above you may want to discuss that matter with your employer so that he can discuss that with the insurance company.
This office can do only so much in helping you with your dental claim. We are not an insurance clearinghouse. We do not have the staff, personnel, or the time to battle with your insurance company. That is not our job. You can be sure we will do our part in providing the correct codes, send the information to them quickly and send the correct information. The dental patient many times believes the insurance company – someone they have no relationship with - when they try to blame the dental office for not having been sent information, the correct information, x-rays, narrative, etc., etc., etc. Insurance companies would love to put a barrier between the dentist and the patient and create doubt. The insurance company hopes you will never get the work done or discourages you from getting any dental work done while still collecting premiums.
Should you become angry, upset or unhappy with the amount of payment, non-payment or slow payment by your insurance company take it up with them - not us. Our main job is to provide our patients with superior periodontal care. Do not let the insurance company put a wedge between you, our professional relationship, your periodontal health and most of all your total health.

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