My Insurance Covers This…….Right?

INSURANCE……it can be our best friend and our worst enemy.  While it can certainly help defray the costs of dental work, it many times does not pay what the patient believes it should pay and ultimately can cause the patient to question the Doctor.  Dental insurance is much different than medical, car, liability and other insurances you may be familiar with.  It can be very confusing to the patient.  My goal over the next few weeks is to utilize our Blog to help patients understand a little bit more about dental insurance and how it works.  I will cover the main questions, features and terminology associated with dental plans.  Please feel free, after reading the information, to contact our office with any questions.  We are here to help as much as we can.

Understanding your dental benefits is not easy. There are as many different plans as there are contracts. Your employer has selected your plan and is ultimately responsible for how your contract is designed. Remember, whether your plan covers a major portion of your dental bill, or only a small amount, dental benefits can help pay for needed treatment.

It is important to know that each contract will specify what types of procedures are considered for benefits. Even if a procedure is medically and dentally necessary, it may be excluded from your contract. This does not mean that you do not need the procedure. It simply means that your plan will not consider the procedure for payment. For example, cosmetic procedures and implants are often excluded from a dental plan.

Here are some answers to a few common questions:

Why doesn’t my insurance cover all costs for my dental treatment?
Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.

But my plan says that my exams and certain other procedures are covered 100%.
That 100% is usually what the insurance carrier “allows” as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge.

I received an “Explanation of Benefits” from my insurance carrier that says my dental bill exceeded the “usual and customary”. Does this mean that my dentist is charging more than he/she should?
Remember that what insurance carriers call “usual and customary” is really just what your employer and the insurance company have negotiated as the amount that will be “allowed” as payment toward your treatment. It is usually always less or even much less than what any dentist in your area might actually charge for a dental procedure. It does not mean that your dentist is charging too much.

Next Blog:  Commonly misunderstood features of dental plans

Lynn Webb
Office Manager