Here you will find some commonly misunderstood features of dental insurance plans.
Appletree Dental will work with your insurance company to provide you the maximum benefit you are eligible for, however, we have your optimal dental health as our main goal and do not allow insurance to dictate your recommended dental treatment.
Does Insurance Pay for Everything?
Employers offer dental benefits to help employees pay for a portion of the cost of their dental care. Dental plans are designed to share in the cost not to completely pay for those costs. Almost all dental plans are the result of a contract between the plan sponsor (usually an employer or a union) and the third-party payer (usually an insurance company). The amount your plan pays is determined by the agreement negotiated by the employer with the insurer. Your dental coverage is determined not by your dental needs but by how much your employer contributes to the plan. Here you will find some commonly misunderstood features of dental plans.
UCR (Usual, Customary, and Reasonable)
Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the dental plan for eligible services. The dental plan pays an established percentage of the dentist’s fee or pays the plan sponsor’s “customary” or “reasonable” fee limit, whichever is less. Although these limits are call “customary” they may not reflect the fees that area dentists charge. Exceeding the plans customary fee, however, does not mean your dentist has overcharged for the procedure. Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in wide fluctuation. In addition, insurance companies are not required to disclose how they determine “usual, customary and reasonable” charges.
Most dental programs have an annual maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period. Some plans run on a fiscal calendar year from July to May, while most run from January to December. The plan purchaser/ employer makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company. The patient is usually responsible for paying costs above the annual maximum. Even though the cost of dental care has significantly increased over the years, the maximum levels of insurance reimbursement have remained the same since the late 1960’s. Your employer may want to research plans that offer a higher annual maximum.
The dental plan may want you to choose dental care from a list of their preferred providers. This is a term that often is applied to dentists who have a contract with the dental benefit plan. Whether or not you chose to receive dental care from this defined group can affect the level of reimbursement and in some cases no benefits are provided to non-preferred providers.
Just like medical insurance, a dental plan may or may not cover conditions that existed before the patient enrolled in the plan. This includes plans that have “missing tooth” exclusion. Benefits will not be paid for replacing a tooth that was missing prior to the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary.
A dental plan may not cover certain procedures or preventive treatments. Some plans exclude certain dental treatments such as sealants, implants, pre-existing conditions, adult orthodontics, specialist referrals and other dental needs. Some also exclude coverage if the procedure was provided by a dentist who is a family member. This does not mean that these treatments are unnecessary. Patients need to be aware of the exclusions and limitations in their treatment plan but should not let those factors determine their treatment decisions. Your dentist can help you decide what type of treatment is best for you.
Plan Frequency Limitations
Certain procedures may simply not be covered as often as necessary for optimal oral health. A common example might be a plan that pays for tooth cleaning only twice a year even though a particular patient may require cleaning every three months. Other plans, for instance, will only pay for sealants once in a lifetime, when generally sealants only last between 5 and 10 years. Limitations may vary depending on the contract purchased. Limitations in coverage are the result of the financial commitment the plan sponsor has agreed to make and the benefits the third-party payer will offer for the commitment.
Not Dentally Necessary
The plan provides benefits for those services and materials that they consider to be dentally necessary and meet generally accepted standards of care. Based on the information your dentist submits, the services may not appear to meet plan criteria and no benefit may be allowed. You or your dentist can appeal the benefit decision by submitting relevant information. The claim, along with the submitted information should be reviewed by the plans dental consultant.
To keep the premium costs down, insurance carriers will incorporate cost-control measures into the plan design. By incorporating cost-control measures during the claims adjusting process, many times benefits are reduced or not paid at all. Some of the more common cost-control measures are:
Bundling — This is the systematic combining of distinct dental procedures by third-party payers that result in a reduced benefit for the patient. A common example of bundling is when bitewing and periapical radiographs are combined and paid as a full mouth series of x-rays. The full mouth series is then subject to the plans limitations of allowing benefits, usually, once every five years for these x-rays.
Downcoding — this is the practice of third-party payers in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements. An example is when the code for debridement is changed to the code for a prophylaxis.
Alternative Benefit — The dental plan may only allow benefits for the least expensive treatment for a condition. For example, the dentist may recommend a resin composite filling (white filling) on a posterior tooth (back tooth), but the insurance may only offer reimbursement for an amalgam filling (silver filling). As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit coverage. In many instances, the least expensive alternative is not always the best option.