Dental Insurance Information

Dental Insurance Information

Making Informed Decisions: Your Dental Insurance.

We have prepared this information to assist you with your dental insurance (NOT HMO/DMO type dental plans, which are not technically insurance). We have increasingly found that more and more patients are not properly informed about the restrictions and limitations that insurance companies impose on their subscribers. This often leads to patients being surprised and frustrated, and we find ourselves placed in the middle. We realize dental insurance can be very confusing. We will always do our best to help you with your insurance.

Please keep in mind that your dental insurance is a contract between you and your insurance company. We cannot control their policies. Their main objective is to pay out the least amount of money as possible. Our main objective is to provide the very best dental care that is possible. Often times these two objectives work well together, as preventative dental care is something we emphasize, and results in lowered dental expenses for all.  Sometimes these objectives do not work well togeher;  when an individual needs comprehensive dental care, what is in the patients best interest, is NOT in the best interest of the insurance companies.

The law mandates that consumers with dental coverage receive from their insurance co., a fully detailed patient information handbook, a ‘Description of Benefits” – that clearly outlines your coverage, limitations, and exclusions. Please make sure that you received the information, and that you fully understand what it contains. Our office is very well versed in the insurance companies confusing lingo, and will be glad to help decipher their information, just ask!

Important things to keep in mind:

Most plans have yearly maximums (and deductibles) that limit your benefits. The renewal date for your annual benefits may vary greatly; it may not necessarily renew January 1. Please keep track of your remaining benefits; we cannot always determine your remaining benefits because you may have utilized some benefits in a different dental office, perhaps a dental specialist. We do not  always have access to what was paid to another provider. Likewise, if you met your deductible in a different office, please let us know. We also need to know if your deductible applies to you as an individual or the family. Most insurance companies limit the number of dental exams and radiographs that will be paid for in a specified time frame. This does not mean that additional exams and radiographs are not needed, only that the insurance company will not pay for them. We do not always know exactly how many exams you have had in other offices in a given year, nor do we know the number of radiographic sets you may have taken in the past 3 or 4 years. Many times we find patients do not know this either, so you can understand how difficult determining benefits can be.  We do our best to obtain as much information as your insurance company will share with us on your behalf.

If you are referred to a specialist, make sure to ask them if they are in your network. We will always do our best to refer you in network (if we refer you out of network, it will be explained why we recommend this), but specialists can drop/add plans without much notice; it is always best to ask when making your appointment with them.

Denial of coverage for a procedure you had completed: this causes a lot of distress for patients, and for good reason. We understand how frustrating and costly it can be when a procedure is completed and benefits that were expected are denied. This is usually out of our control, but things can be done to minimize this from happening. The first and obvious strategy is to know all the details of your plan. If you are due to have treatment that will cost more than a few hundred dollars, it is always advisable to obtain a pre-determination of benefits. Please remember that even the printed word from your insurance company is not guaranteed. Their paperwork will always have fine print stating: “we cannot guarantee the information contained in this pre-estimate, benefits will be determined at the time treatment is rendered.” What they mean is that if we obtain an estimate in March, and in April the treatment is completed but the plan was not valid in April, benefits will be denied. This is their catch all excuse for denying benefits. There are other reasons insurance companies deny benefits, but rest assured we will fight to obtain the benefits that you are entitled to.

Some of the ‘excuses’ and limitations we have come across are:

  • The patient exceeded the yearly maximum.
  • The patient has a waiting period for that type of service (even though it may have been necessary)
  • The insured’s (you) group was dropped entirely (this can be for a number of reasons)
  • The particular type of treatment is not covered (even though it may have been necessary)
  • An alternative type of treatment was paid for (ALWAYS a less expensive form of treatment, not the best!)

The last item listed above is a very common technique insurance companies use to minimize their costs. They may not cover certain types of emergency treatment. They may pay for a removable denture instead of a fixed bridge, or a silver mercury filling instead of a bonded tooth colored one. These are less than ideal treatments, and the insurance company is not preventing you from having the best care, they are just not willing to pay the benefits for the better treatment. In our office, we will always give you all your options to restore your mouth to optimal health. We will not base our treatment decisions on insurance company limitations. You are free to weigh all your options and let us know what your choices are. Please note that our office is mercury free, silver mercury fillings are not utilized.


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