Coverage provided by dental insurance may vary widely from plan to plan. Though it is very rare to see a plan that covers 100% of all dental services, a good insurance plan can help pay a substantial portion of your dental bills.
Types of Dental Plans
Most of the patients we see have PPO (Preferred Provider Organization) plans, in which patients receive the highest level of benefits for selecting a “preferred provider” that participates in their plan. These providers have agreed to discount their fees for plan members. If the patient goes to a non-participating provider, he or she may face some additional out-of-pocket expenses. Our office participates in most of the major PPO plans and adds new plans from time to time.
A smaller number of patients have more “traditional” plans that allow them to go to any dentist they choose. Our office does not participate in HMO (“Health Maintenance Organization”) plans, which require the patient to go to a specifically assigned dentist. Please make sure you contact your plan or visit its website before you make an appointment to make sure they will cover services at our office.
Coverage for Services
Generally, dental insurance covers all or most of preventive and diagnostic services, such as periodic cleanings, routine exams and x-rays, as well as problem-focused exams. The patient will likely owe little or nothing out-of-pocket for these services. Basic restorative services such as fillings, endodontic services such as root canals, and oral surgery services such as extractions, are covered at a slightly lower level, typically 80%. You may also be required to pay a yearly deductible, usually under $100, before insurance will cover these basic services or major services, such as crowns and bridges. Major services usually have the lowest coverage level, often only 50%.
Sometimes insurance plans have waiting periods, missing tooth clauses, frequency limits or other special restrictions that may affect whether or not they will pay for a certain procedure on any particular visit. Our office staff does their best to determine this information directly from your insurance company at the time of your first visit so that we can better anticipate what your out-of-pocket expenses might be. However, please be aware that this is done on a courtesy basis, and ultimately each patient is responsible for any fees that are not paid by his or her insurance.
What You Will Owe
At each visit, we will calculate your estimated patient portion based on the most current information provided to us by your insurance company, and we’ll ask you to pay that amount at the time the services are rendered unless other special arrangements are made. As a courtesy to you, we will complete and file your insurance claim for each visit. The insurance company may then pay us their portion directly, rather than your paying us the full amount and waiting for insurance to reimburse you.
Occasionally, insurance pays somewhat more or less than what is estimated due to changes in their fee schedules (their list of discounted fees that we have agreed to honor) or other unanticipated decisions to disallow or reduce coverage for certain procedures. In the event that our estimate varies from the actual amount the insurance pays, any overpayments by you will be promptly refunded or kept on your account as a credit for future services, as you choose. Alternatively, we will send you a statement for any remaining amounts not covered by insurance.
Be assured that we work directly with your insurance company to appeal any questionable underpayments or denials so that you may receive your maximum benefits. Likewise, we will work with you to find the most financially feasible way for you to handle your portion of your bill. In return, we ask that you promptly respond to any communication from us about your account so that any payment issues can be resolved quickly and to the satisfaction of everyone involved.
We appreciate your business!