Facts Concerning Dental Insurance

Fact #1: No insurance pays 100% of all procedures

Dental insurance is meant to be an aid in receiving dental care. Many patients think their dental insurance pays 90% to 100% of all dental fees. Most plans only pay approximately 50% to 80% of the average total fee. Some pay more, some pay less. The percentage is usually determined by how much you or your employer has paid for the coverage or the type of contract your employer has set up with the insurance company. Dental insurance benefits differ greatly from general health insurance benefits. In 1971, your dental insurance benefits were approximately $1,000 per year. In 2013, you will note that your benefits are still $1,000 per year. Figuring a 6% rate of inflation per year, you should be receiving over $5,000 per year in dental benefits. Your premiums have increased, but your benefits have not. Therefore, dental insurance is never a pay-all; it is only an aid.

Your dental insurance is a contract set up between the employer and the insurance company.You get back only what your employer put in, less the profits of the insurance company.  Kirksville Dental Group will assist you as much as we can but if additional questions regarding your benefits arise, it is best to contact your employer.

Fact #2: Benefits are not determined by our office

You may have noticed that sometimes your dental insurance reimburses you at a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual customary, or reasonable fee (“UCR”) used by the insurance company.

A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentist in the area charge for a certain service. This can be very misleading and simply is not accurate.

Insurance companies set their own fee schedule and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR fee. Frequently this data can be 3 to 5 years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit.

Unfortunately, insurance companies imply that your dentist is “overcharging” rather than say that they are “underpaying” for procedures. In general, the less expensive insurance policy will use a lower UCR figure.

You may be surprised to know that dentist are not involved in determining the terms of your dental benefits, including procedures your insurer will cover, or at what fee allowed amount. Dental insurance is actually a contract negotiated between your employer and the insurance company providing the dental benefits, not your dental office.

Fact #3: Deductibles & Co-Payments must be considered

When understanding dental benefits, deductibles and co-payment percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, you can calculate the benefit that you will be reimbursed. First a deductible (if applicable), on average $50.00, will be subtracted, leaving a $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of the $100.00 or $80.00. Of course, if the UCR is less than $150.00 or your plan maybe only pays 50%, then your insurance reimbursement will be significantly lower.

Most importantly, please keep our office informed of any insurance changes such as policy name, insurance company address or change of employment.

The goal of most dental insurance policies is to provide only basic care for specific dental service. It is important to understand that the dental benefits you receive from the insurance company have nothing to do with your individual needs or achieving the best results. Many services needed for your dental health may not be covered.

As a courtesy, our office will complete and submit your insurance forms to achieve the maximum reimbursement to which you are entitled. Please do remember, however, that ultimately you are responsible for all expenses incurred. We urge you to read and review your dental policy so that you are fully aware of your insurance coverage.