Dental Insurance: The mystery

Posted on Aug 27, 2014 in News | 0 comments

A lot of my patients don’t understand how their insurance works and two of the the biggest questions I have from the patients is “IS MY INSURANCE GOING TO PAY FOR MY TREATMENT?andIF YES, HOW MUCH ARE THEY GOING TO PAY?
Easy question to ask, but DIFFICULT to answer.

After all these years in practice, this is what I make out of it. Dental Insurance is different from Medical insurance. Medical Insurance usually has a fixed copay when you go in for a doctor’s visit. Dental Insurance is of various types. Again, this is my analysis after being in practice for a long time.

Indemnity Dental Insurance is a plan where you go to any dentist you want. The insurance company may pay the dentist or the patient. There is usually a maximum amount allowed per year. Each procedure is covered at a certain percentage based on your plan. There is usually a deductible and a co-pay that you have to pay based on the procedure. There are other limitations based on the plan.

Dental PPO or DPO is a plan where you can go to any dentist the you want, BUT if you go to a dentist who is participating with the PPO or DPO plan, your copays are less because the dentist is supposed to take the fee set by the insurance company. If you go to a non-participating dentist, your copays may be higher. There is usually a maximum amount allowed per year. Each procedure is covered at a certain percentage based on your plan. There is usually a deductible and a co-pay that you have to pay based on the procedure. There are other limitations based on the plan.

Dental HMO is a plan where you see a specific dentist that you pick at the time of enrollment. This plan covers your preventive and basic treatment with set copays and asks that you pay for all the other procedures at the fee set by the insurance companies.

Coming back to the question: WILL MY INSURANCE PAY FOR MY WORK?

Once your check up and treatment plan is done, we give you an estimate of what your insurance will pay on the procedures you need to get done, based on the information provided by your insurance company. It is never a guarantee as we don’t work for the insurance. We participate with certain plans and agree to take the fee set by the insurance company. If you want a firmer answer, we send a pre-determination to your insurance company listing all the procedures that you need and they send you and us paperwork with the details of what they are going to cover. It is a better estimate but still not a 100% guarantee. This pre-certification takes about 2-4 weeks to get back from the insurance company.

Unfortunately, dental treatment, once explained and agreed upon should not wait, especially emergencies, fillings, extractions, infections, root canals etc., as the situation may get worse. For eg., a large cavity might grow bigger and bacteria might enter the nerve tissue. If delayed, then you would need a root canal instead of a filling. OR an infection may spread further and cause more discomfort and might take more time to heal etc.

Coming back to the question, DENTAL INSURANCE is a tool to help you pay for your treatment, but treatment planning by the dentist and treatment acceptance by the patient should be based on oral & dental condition and treatment plan provided by the dentist and not on what the insurance pays for.

Our office strives to get you the best and most information as far as we can, but we do not work for the insurance company.

Any questions, please ask for more details.

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