Why Doesn't My Insurance Pay for This?

     Dental insurance is a benefit offered by many employers.  It actually works more like a valuable "coupon" that can reduce the cost of your dental treatment.  It is important to remember that dental benefit plans do not cover all of the cost of dental treatment.  Hopefully this post will help to clarify how dental benefit plans work.
      It is important to remember that dental benefits offered by a plan should not be confused with dental treatment that is needed.  Dental benefit plans are a contract between your employer and an insurance company.  The dental treatment you need is determined by your dentist.  Your dental coverage is not based on what you need or what your dentist recommends.  Your dental coverage is based on how much your employer pays into the dental benefit plan. 
     At Clearwater Dental Associates, our main goal is to help you take good care of your teeth and provide excellent dental care for you and your family regardless of the stipulations of a dental benefit plan.  As a courtesy to our patients, we file dental claims with the insurance company.  We ask that the portion NOT covered by insurance be paid at the time of treatment. 
     Dental benefit plans use the term UCR (Usual, Customary & Reasonable) when they refer to the maximum charge for treatment that they allow.  The insurance company will make it seem that their UCR is the standard rate that most dentists charge for their procedures, but this is incorrect. 

• UCR charges usually do not reflect what dentists usually charge
• Insurance companies can set whatever UCR fees they want, they are not required to match actual fees charged by dentists in the area where you live
• An insurance company does not update their UCR amounts to keep with rising costs.  Often, they keep their UCR amounts the same for many years.
• Insurance companies are not required to say how they set their UCR rates. 

If your dental treatment costs more than what your insurance company has set for their UCR, it does not mean that your dentist has overcharged you. It means that your insurance company has not updated their UCR amounts, or the data the insurance company is using to set their UCR rates is not reflective of the state you live in.
    
     Another confusing issue with dental benefit plans are the terms PPO, DHMO, and Preferred Providers.  PPO and DHMO refer types of dental benefit plans companies offer.  A PPO type of plan gives patients the option of going to an "in-network" or "preferred" provider or they can go to an "out of network" provider.  An "in network or preferred provider"  means that the dentist has signed a contract with an insurance company and the fees charged are pre-determined and cannot be changed.  The benefit of a PPO type of plan is that if someone does not want to change dentists, they can go to an "out of network" provider and still use their dental benefits.  The out of pocket amount owed may be more, but that can be determined before dental treatment is rendered.
     DHMO dental plans do not give the patient the flexibility of going to an "out of network" dentist.  The dental benefits can only be used at an office with a dentist who is an "in network" DHMO provider.  If a patient goes to a dentist who is NOT a DHMO provider, the insurance will not pay anything.
     All dental benefit plans come with an annual maximum.  This is the largest dollar amount that the plan will pay out during a year.  The annual maximum is decided in the contract between your employer and the insurance company.  Annual maximums are not always updated to keep up with the costs of dental care.  In the 1980's the average annual maximum was about $1000 per year, and today the average annual maximum is only about $1500 per year.

At Clearwater Dental Associates, we have dentists who are contracted with some insurance companies, thus they are "in-network".  We have dentists who are contracted with Argus, Assurant, Cigna, Delta Dental Premiere, DeCare, Metlife, Prinicpal,  and United Concordia. 

Although you may be tempted to make decisions about your dental care based on what your insurance will pay, just remember that your dental needs are determined by your dentist and the least expensive option is not always the best.