Copper Canyon Family Dentistry Dental Insurance
There are lots of dental insurance companies out there, and each carries various plans available to patients. Each plan differs in the small details of what is covered, and what is not. There are employer-based plans (which have worked out their own details on what is covered), and there are private insurance plans available. Each plan within each company is entirely different, so it’s important to know the details of your specific plan.
Dental insurance is similar to a “benefit program” where patients pay a monthly premium to an insurance company, in exchange for receiving discount rates on services, and having the insurance company pay a percentage of certain procedures. Not every procedure is covered by insurance, and for the procedures that are covered – the percentage that the insurance company is responsible for varies. Some plans require patients to pay co-pays, or to reach a deductible before the insurance company is responsible for reimbursement.
Unlike medical insurance, even when procedures are a “covered benefit” through an insurance plan, there are no guarantees that the dental insurance company will cover the procedure because often there are restrictions on how frequently that procedure can be reimbursed, or restrictions on what diagnoses are covered. You also must be aware of what your annual benefits are – in other words, your insurance plan will only pay out a certain amount per year toward treatment done.
Navigating the dental insurance world is tricky – and plans vary not just by the insurance company, but also by the employer. We encourage you to learn the particulars of your plan and feel free to call your insurance company, or your HR department, to receive clarification. Our staff are also working to help understand the intricacies of your plan by calling your insurance company for you. Sometimes we are limited on the information we can receive, so it works best when we can work with you to understand what benefits you have.
Regardless of your insurance plan, know that we are always going to take care of you – making sure that we evaluate you, diagnose any conditions and make treatment recommendations so that you can be informed of your oral health and your options.
Q - I don’t understand why I still have out-of-pocket expenses when I am paying a monthly premium to my insurance company?
A - Each plan is different, but typically dental insurance plans negotiate down the standard fees of an office, then cover a percentage of that cost. The patient is responsible for the remaining percentage. The actual percentage that is covered varies by the procedure. Most times, exams, cleanings and certain x-rays are covered at 100% and other treatments will vary in their coverage. Some procedures have 0% coverage by insurance companies, but the patient can still use a negotiated fee for that procedure.
Q - I received an “Explanation of Benefits” from my insurance company, and they have denied the claim. I checked my contract and it states that the procedure that I had done is a covered benefit, so why is my insurance company refusing to pay?
A - Typically, when a patient receives an Explanation of Benefits (or “EOB”), our office will too, and we will review it for accuracy. If we believe that the procedure should have been covered by your insurance company, we will resubmit the claim – usually with additional x-rays or photographs from your chart, and a narrative written by the doctor who saw you. Sometimes, the procedure is denied due to special clauses or wording that is in your insurance contract. Examples might be restrictions to how often you can have a certain procedure completed, or a waiting period before the insurance company is willing to reimburse a procedure. We do our best to ask your insurance company about some of these details before we complete the procedure, but in some cases we are limited to how much of this information they are willing to provide us. This is why we encourage our patients to get to know the details of their plan, and call and ask their insurance company for clarification if needed. Sometimes, by calling directly, patients can gather more information than we can.
Q - Why do I have a co-pay to pay in addition to my monthly premium?
A - Each contract between a patient and their insurance company is different, and so is the payment arrangement. There are lots of plans out there that do not require a co-pay. If you prefer to have a plan without a co-pay, contact your insurance company or HR department and ask if there is a different option available to you.
Q - I had a partial denture made for me a few years ago, and my insurance paid their estimated portion for it. I have now decided that I would like to get an implant instead to replace my missing tooth, but the insurance company is refusing to pay because they paid for my partial. I don’t understand.
A - This is an interesting situation we have encountered where the insurance company feels that they have already reimbursed for a similar procedure by paying their portion on the patient’s partial denture. Before they will pay again to replace the same missing tooth, even if it is being replaced in a different way, any restrictions to the frequency of replacing that partial denture will apply. This can be confusing for a patient, and challenging for us because this type of restriction does not always apply. We encourage you to contact your insurance company or HR department, or refer to your insurance contract, to find out the details on these types of restrictions.
Q - When I received my treatment plan, I was given an estimate on what my out-of-pocket cost would be and what my insurance company was expected to pay. They paid less than expected, and so I had to pay the difference. Why did this happen?
A - When we draft a treatment plan for a patient, we are estimating what percentage of the procedure cost that the insurance company will pay - which helps us to calculate what the patient’s cost will be. Despite what information we receive from your insurance company, there are still times when they will pay more or less than expected because they do not guarantee the accuracy of their estimates. This leaves the patient with either a credit (in the case of over payment) or a balance (in the case of underpayment). If we believe there is an error by the insurance company, we will contact them to see about receiving the correct payment.