During the past decade, dental benefit plans have become an integral part of health care planning for many families. Dental benefit plans are made available to employees or members through companies, unions, and associations, and may vary considerably from one plan to the next.
The range of benefits depends solely on what the purchaser wishes to offer employees or members. Some plans may cover as little as 30% or as much as 100% of dental services, with most falling in the 50% to 80% range. Some plans exclude certain types of services, i.e. orthodontics, while other plans will cover a full range of dental services.
Some plans base the amount of benefit on a chart or schedule of what they label as UCR (Usual, Customary, Reasonable) fees which are developed arbitrarily low by insurance companies in order to limit their cost. For this reason, you may receive a lower percentage of the reimbursement level than you expected from your dental plan. For example, your plan may state that it will pay 100% of their fee schedule which will usually be below the actual fee charged for the dental service provided.
Certain assumptions have become evident and we would like to make the principles of our practice, as well as the type of service and care we provide very clear:
Our fees are based on the overhead involved in our practice, the treatment plan selected, and the time it takes us to provide you with the necessary dental care. We do not believe it is in either of our best interests for us to compromise our recommended treatment in order to accomodate an insurance program's maximum benefits that may be considerably less than optimal. However, we are more than happy to discuss a treatment plan's advantages and disadvantages with you thereby involving you, rather than your insurance company, in the decision making process.
The type of treatment you need and receive from us is based upon our professional judgement, and not on whether you are covered by a dental benefit plan. As an example, bonded composite or porcelain restorations for posterior teeth are far superior to the old amalgams. Bonded restorations are stronger, create a better seal and provide long term protection. The cheaper "alternative treatment" pushed by most insurance carriers is the mercury containing amalgam. The inevitable leakage around amalgams leads to corrosion and expansion which will result in eventual fracture of part or all of the tooth resulting in the need for root canal therapy, a crown or extraction. When this need arises, the insurance company limits how many can be done in one year with the yearly maximum and a significantly reduced percentage of coverage (major work with usually only 50% of their fictitious fee covered). A win-win for them and a lose-lose for you. The harsh reality is the insurance companies exist only if they make a profit on the premiums you or your employer pays and that is where their profound judgement is coming from. The best solution to this reimbursement shortfall is Direct Reimbursement.
As a courtesy to you and to expedite processing, we will complete the dental portion of the claim form. To aid us in processing, please make sure that you supply our office with accurate and up to date information.
If your dental plan requires a "pre-determination" or "prior authorization", we can submit a treatment plan for review by your carrier. This is not a guarantee but only an estimate of what portion the insurance company may pay toward the cost of a specific procedure. If we provide care without a "pre-d", your insurance company is still obligated to provide you with it's usual level of reimbursement plus there is an advantage to you of not having to wait for unneccesary paper handling or bogus claims that they never received the x-rays or paperwork. We usually can obtain an estimate over the phone which gives us the same information as a "pre-d". Please remember that the financial obligation for dental treatment is between you and this office. The insurance company is responsible to you and not to this office.
If you receive a communication from your insurance carrier suggesting that the "fee is over and above the UCR for the services provided," this is insurance company double talk for the reality that the insurance carrier's fee data is out of date or arbitrarily low in order to limit their cost of reimbursing you.
We will help you, in every way in filing your claims, handling your insurance questions, processing follow-ups, lost claims, narratives, etc. No question is too small for you to ask, whether it is about your treatment, benefit plan, or statement. Please stop in or call any time you have a question. We are here to help you
Call for a relaxing, informative visit with Dr. Schwan
at (610) 431-0700 today!
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