FAQ:  A Guide to Dental Insurance

Q. Why doesn’t my insurance pay all my costs for dental work?

A. Dental insurance is a money benefit typically provided by an employer for their employees to pay for routine dental care. Your employer usually buys a plan based on the monthly premium that he can afford and how much benefit that premium buys. Most plans only cover a portion of the total cost of dentistry.

Q. My plan says they pay 100% of exams and other procedures, but I still got billed for dental work. Why?

A. That 100% (or other percentage) is only of what the insurance company allows for each procedure and not what a dentist may charge. For instance if an exam costs $90 (not counting x-rays), but the insurance company only allows $60 then you will be required to pay the additional $30 of the fee. If there is a yearly deductible, that may also decrease what they will pay.

Q. How do insurance companies come up with those allowed amounts?

A. Most carriers call these amounts UCR which means “usual” “customary” and “reasonable” however those terms don’t exactly describe what the amounts are. UCR is just a list of payments for each covered procedure that that employer (or you) negotiated for the premium cost per month. Obviously, the more your premium, the more the insurance company will pay. UCR really means “negotiated” amount.

Q. On my EOB (explanation of benefits) from the insurance company, it says my dental bill exceeded the UCR – is my dentist charging too much?

A. Again, UCR has nothing to do with what most dentists charge for a procedure, but reflects what level of plan benefit your employer has negotiated with the insurance company. Your dentist isn’t charging too much.

Q. My EOB says that I exceeded my yearly maximum. What does that mean?

A. For the premium your employer pays to the insurance company, another negotiated rate is the amount of money that your plan will pay out in any given year (typically a calendar year). If your yearly maximum is, say, $1000 – once you have that much work done in a year, the insurance company will pay nothing more. Despite that fact that costs have risen steadily, yearly maximums have been locked into payout amounts established in the 1980s, so it is easy to use up all your benefits on fixing one badly broken down tooth (for instance).

Q. I have a plan that requires me to select a dentist from a list. Why is that?

A. Some plans have contracted with a group of dentists to accept lower fees in exchange for sending them patients. In certain instances you may go to dentists not on their list, but you will have to pay more of your bill - keep that in mind. In other instances you will get no benefits paid by your insurance company if you do not go to a dentist on their list. For that reason it is important to check with the insurance company and your Employee Benefits Coordinator at your place of business because you will owe the full bill for dental services regardless of what the insurance company pays.

Q. Why doesn’t my dentist participate in those plans?

A. Many of those plans place restrictions on how the dentist can treat their patients and many dentists aren’t comfortable with this. The heavily discounted fees also change how most dentists need to work in order to keep their business profitable (cutting corners on supplies for instance). So more likely than not the offices that accept those plans are usually high volume franchises.

Q. Why did my insurance company only pay for the least expensive alternative treatment?

A. To save money, many dental plans are written to allow the insurance company to “downcode” a procedure to the least expensive treatment that can be done on a tooth. For example your tooth may require a crown, but your insurance company will only pay the benefit for a filling. That doesn’t mean that you only need a filling, but that your plan will only cover a filling. Also, most white plastic fillings cost more than silver fillings yet the insurance company will only pay the cost of a silver amalgam. If you wish to have the more expensive procedure, keep in mind that the extra fee will be your responsibility. The dentist recommends treatment based on what he thinks you need while the insurance company is only interested in profits.

Q. I’m not sure when my insurance plan is in effect. Can we bill when I know?

A. State laws regulate these issues closely and it is insurance fraud to code a date other than the date you actually do a procedure. If your plan is not in effect at the time you have work done, the carrier will not pay anything. For that reason it is critical that you find out from your employer or your insurance company exactly when your plan is in effect. Sometimes the insurance company records are incorrect so if you believe you have coverage, but they say you don’t – have your Employee Benefits Coordinator attempt to straighten things out with your carrier before you have the dental work done. Your plan may even change the levels they pay or you may lose your eligibility if you don’t work enough hours. So again you need to be a wise consumer and track you individual plan benefits.

Q. What should I do if my insurance company doesn’t pay for treatment I think should be covered?

A. Your insurance coverage is between you, your employer, and the insurance company. Your dentist doesn’t have any power to make your carrier pay, but as a courtesy will often attempt to explain to the carrier why they should pay. Every plan is different and your dentist can contact the company to get you help, but it is up to you to pursue the carrier if you believe they should have paid more of your claim. Your Employee Benefits Coordinator at work may also be of some help. For rare circumstances, you may lodge a complaint with the Colorado State Insurance Commission.

Q. My insurance company still won’t pay. What went wrong?

A. Your dentist is in the business of fixing your teeth. As a courtesy, they will often handle your insurance claims for you but you need to remember that your plan is between you, your employer, and the insurance company - not your dentist. The dental office has no control over what the carrier will pay and can only bill for the procedures that they perform. If you are unhappy with the level of payment from the carrier, you should talk to the carrier or urge your employer to improve your plan (or switch companies). Bottom line- insurance companies are in business to make a profit so paying them $100 in premiums and expecting them to pay you $1000 in benefits is not realistic.