Insurance Q&A

We get many calls regarding dental insurance, how it works and why certain procedures are covered while others aren’t.  Here is some information that you may find helpful as you evaluate your insurance options.

Is dental insurance is similar to medical insurance?

ANSWER:  Dental benefits can help pay for limited services such as preventive care (cleanings and check ups) and some single tooth or single quadrant dentistry within a calendar year.  Benefits are so limited that they pay for a very small percentage of the fees for multiple tooth dentistry and complex treatment plans.  Some dental procedures are not covered at all by dental benefits.  This does not mean that a procedure recommended by your dentist isn’t necessary, it means that insurance companies do not cover all procedures even if it may be an important factor in maintaining your oral health.

I should ask the doctor to limit treatment to those items covered by my dental benefits?

ANSWER:  We have an ethical obligation to diagnose and share our findings with you.  We base our treatment recommendations on the needs of the patient, not the limitations of the benefits.  We respect your right to make decisions regarding your oral health, but we want you to be totally informed.

If the doctor is not on my plan, will I receive any benefits?

 It all depends on the plan.  Even if we are not on your “Provider” list, many plans still provide the same percentage of coverage, just on an out-of-network basis.  Other plans are more restrictive and require you to see a particular dentist in order to receive benefits.  We deal extensively with insurance plans and are happy to call on your benefits for you to avoid any unexpected surprises.

Are insurance companies a good source of information regarding dental fees?

ANSWER  Insurance companies base their “usual and customary” (UCR) fees on averages.  The companies have no incentive to keep these statistics up to date (because it would cost them more money), and our practice is not average.  The fees you pay here reflect the quality of care you receive.  Another little known fact is that UCRs can be different even with the same insurance company depending upon the type of plan purchased by the employer.

Is there a difference between your fees and the amount the insurance company will pay?

ANSWER Insurance company maximums have barely increased in the last 30 years!  During that time, there have been many scientific advances in dentistry that we incorporate into our practice for your benefit.  We provide 21st-century dentistry and we are certain that you would not like us to turn back the clock and only offer you what was available in the 1970’s.

Do I have 100% coverage?

ANSWER There is no such thing as full coverage.  Even plans that offer 100% coverage on preventive services such as cleanings or exams still have frequency limitations allowing only a limited number of services regardless of your needs.  No matter what type of coverage you have we will do everything possible to help maximize your benefits while addressing your dental needs.

We deal with many insurance plans on a daily basis so we are often able to spot red flags regarding insurance limitations. However,  there are literally hundreds of insurance plans available and it is important all patients are knowledgeable about their own plan, it’s benefits and limitations.  We are happy to help in any way possible, call our office anytime if you would like help!

Thanks to Dr. David Schwab for allowing us to use his information for this article. Dr. Schwab has previously served as Director of Marketing for the American Dental Association and as Executive Director of the American College of Prosthodontists.