This blog is part one of a three-part series on the current state of the dental insurance industry, written by industry thought leader and Whiteboard Marketing Market Advisory Council member, Nick Sanyk of Smile Hilliard.
Do You Take My Insurance?
One of the most common questions we get is if we “take” or “accept” a patient’s insurance. Smile Hilliard is able to accept any Preferred Provider Organization (PPO) dental benefit plan that allows you to select the dental provider of your choice. If you have a PPO plan, we can file claims and accept assignment of benefits on your behalf!
We will always do our best to utilize your insurance benefits when possible, however we are not an “insurance driven” practice in that we do not make our treatment recommendations based on insurance plans limitations. We care about you and your dental health, and will work with you and your benefits plan to meet your oral health goals.
In Network vs. Out of Network
An “In Network” provider is a dentist that has agreed to a contract with an insurance company. This is essentially a give-and-take relationship. The contracted dentist agrees to accept certain discounted fee rates for services in exchange for being listed as a “preferred provider” for that insurance carrier.
For the insurance company, this helps keeps their costs down in that they pay out less for your dental claims. For the dentist, it helps to keep their chairs full by driving patients to their office.
An “Out of Network” provider is a dentist that has not agreed to a contract with an insurance company and is not required to follow their fee structure. A non-contracted dentist is also not required to follow many restrictions that are imposed by the insurance company which put limitations on the care that you receive. This allows you and your dentist the freedom to make the decisions regarding your care, rather than the insurance company.
Most of our patients rely, in some part, on dental insurance to help pay for the cost of their dental treatment. We believe that patients deserve respect on this issue and we are upfront on which carriers we are contracted with and which we are not. A patient may have lower out of pocket costs at an in network provider, but not always.
Often, we find that a patient’s out of pocket cost is no different in network compared to out of network. Not all insurance companies are the same, and some are better than others. We will always present you with a treatment plan including any estimated costs prior to completing any dental work at our office.
If you ever have questions as to the contractual status of our practice with your benefits plan, please contact us and we’ll be happy to answer all your questions.
Verification of Your Benefits
Dental insurance, by design, is very complicated, highly variable and has many inherent flaws. Dental insurance is not actually insurance at all, it is more of a discount plan.
Insurance companies make their plans confusing on purpose, so that patients become frustrated and end up not completing the treatment they need, creating huge profits for the insurance industry.
At Smile Hilliard, we do an extensive verification of your dental benefits prior to your first appointment, which allows us to give you the most accurate estimate possible of the cost of your dental care. Our goal is to help you receive the maximum value of the dental benefits for which you’ve paid.
No one likes getting a surprise bill that they weren’t expecting. We are very proud to say that due to our detailed verification process, your dental claims will almost always pay exactly as estimated in our office!
Maximums & Deductibles
A dental plan’s maximum is the most that the insurance company will pay out towards claims during a given benefit period. A benefit period is generally based on the calendar year, but can also be based on a fiscal year or plan year starting in a month other than January.
Most dental plans only allow for a maximum benefit of $1,000 per year per covered individual. Unfortunately, insurance companies have not raised these maximums in decades, and the annual limit can be reached quite quickly when significant treatment is diagnosed.
Additionally, due to today’s hectic lifestyle, many patients do not utilize their dental benefits before they expire or terminate. When this happens, the patient loses and the insurance company wins.
A dental plan’s deductible is the amount the insurance company requires the patient to pay before their insurance begins to pay benefits towards treatment. Typically, the deductible applies to basic and major services only and does not apply to preventative services such as exams and cleanings, but not always.
Under some plans, the deductible may apply to some or all x-rays, or all preventive and diagnostic services as well. Once the deductible has been met, then the insurance company will begin to pay their percentage of eligible services.
Insurance companies often have many rules and restrictions designed to prevent them from paying benefits towards your treatment. Examples of these include frequency limits for services, waiting periods, missing tooth clauses, and alternate benefits allowances.
It is a good idea to read the fine print of your policy documents so you can be aware of these restrictions. These rules are determined between your employer and the insurance company and are based on the quality of the plan selected.
A dental “pre-estimate” is a way of providing a more accurate idea of what the insurance may pay and the portion that the patient is responsible for before any services are rendered.
For some insurance carriers, this process is quick, but for most it takes 30 days or more. Normally, a pre-estimate is only sent if the diagnosed treatment is unusual or complex, if the treatment is scheduled very far out, or if there is a question regarding an undefined answer (age of an existing restoration, when a tooth was lost, etc.).
With our detailed verification process, a pre-estimate for routine services is usually not necessary. Waiting for a pre-estimate is a tactic used by an insurance company to make a patient delay the treatment they need.
Lastly, a pre-estimate is still not a guarantee of benefits and only once an actual claim has been submitted and processed will an insurance company determine payable benefits.
Coordination of Benefits and Secondary Insurance
Coordination of Benefits takes place when a patient is entitled to benefits from more than one dental plan. The two plans will coordinate benefits with each other to eliminate benefits duplication.
Normally, secondary insurance will not accept a claim until after the primary claim is paid, and the secondary policy will require a copy of that payment information (referred to as an Explanation of Benefits, or EOB).
Most dental plans have non-duplication of benefits and/or “carve out” clauses or other restrictions that limit payment. It is nearly impossible to predict what secondary insurance may pay until after the primary insurance has paid their portion. Therefore, we are unable to estimate secondary insurance benefits, however we will still file these claims on your behalf.
In the event that secondary insurance pays additional benefits, we will contact you to refund any resulting credit balance or it can be kept on your account to be put towards future treatment. You will always receive the full benefit allowance of both dental plans.
As you can see, dental insurance is very complicated and very different from medical insurance. For additional information, a great article that discusses this topic in more detail is available here: The Trouble With Dental Insurance.
NOTE: This blog was initially published on Smile Hilliard’s practice blog on August 23, 2021 under the title Common Dental Insurance Questions. The author has since edited and updated all information to be current as of publication.