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How are Appointments Scheduled
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Do I Stay with My Child During the Visit
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Our Office Policy Regarding Dental Insurance
Understanding Your Dental Insurance Benefits
Monday - Friday:
8:00 a.m. - 5:00 p.m.
The office attempts to schedule appointments at your
convenience and when time is available. Preschool children should be seen in
the morning because they are fresher and we can work more slowly with the
child for their comfort. School children with a lot of work to be done
should be seen in the morning for the same reason. Dental appointments are
an excused absence. Missing school can be kept to a minimum when regular
dental care is continued.
Since appointed times are reserved exclusively for each patient we ask that you
please notify our office 48 hours in advance of
your scheduled appointment time if you are unable to keep your appointment.
Another patient who needs our care could be scheduled if we have sufficient
time to notify them. We realize that unexpected things can happen, but we
ask for your assistance in this regard.
We
invite you to stay with your child during all appointments.
Many pediatric dental practices suggest that parents wait in the
reception area while their child is being seen.
Our philosophy is quite the contrary.
We believe that helping parents raise healthy smiles is a
partnership between you and your children and our dental team.
Communication to both parent and child about their total oral
health is key to averting future complications and building great dental
habits for life. For this
reason we love the opportunity of talking with you and your children
together at their appointments.
Payment for professional services is due at the time
dental treatment is provided. Every effort will be made to provide a
treatment plan which fits your timetable and budget, and gives your child
the best possible care. We accept cash, personal checks, debit cards and
most major credit cards. We also partner with "Care Credit" to allow
families with larger treatment plans to pay for their services over 12
months at $0.00 interest.
Our policy regarding your dental insurance benefits
goes beyond simply submitting the claims for you.
We feel it is just as important to educationally understand your
insurance choices, benefits and how to best utilize them as it is to
understand the dental treatment choices we recommend for your child.
Similar to our beliefs regarding dental treatment, we pledge to
stay as up to date as possible on the ever changing world of insurance
benefits, relay the general concepts to you and help you make choices
which make sense for your individual family’s needs.
Once you’ve agreed to the treatment we propose and upon
completion of the work, we will submit the claims to your insurance
carrier. At times, it is
necessary to challenge the decisions of the insurance company in order
to gain the benefits you deserve.
As a customer service oriented practice, we take it upon
ourselves to utilize our in-house insurance specialists to pursue these
issues in your behalf. If
you have any questions at any point of the process, please do not
hesitate to contact our insurance specialists.
Fact 1 – DENTAL
INSURANCE PLANS ARE DESIGNED EXTREMELY DIFFERENTLY THAN MEDICAL
INSURANCE PLANS
Dental insurance benefits differ greatly from traditional medical
health-insurance benefits and can vary quite a bit from plan to plan.
Where medical insurance was designed with the intent of covering the
majority of costs, dental insurance was designed as a supplemental aid
to the individual’s costs. When dental insurance plans first appeared
in the early 1970’s, most plans had a yearly maximum of $1000.00.
Today, most plans still have an annual maximum of $1000.00. Over the
past 40 years, the premiums have certainly increased yet the benefits
have not increased. Allowing for a conservative 6% rate of inflation,
your yearly plan maximums should be in excess of $5,000.00 today. Your
premiums have increased, but your benefits have not. Therefore, dental
insurance is never a pay-all. Instead we must think of it as a great
aid only.
Fact 2 – BENEFITS ARE NOT DETERMINED BY OUR OFFICE
Dental
insurance is a contract between your employer and a dental insurance
company. The benefits you receive are based on the terms of the
contract that was negotiated between your employer and the dental
insurance company. At times, the benefits negotiated do not align with
the dental needs of the patient. In fact, even within an insurance
company, like Metlife, there are several different types of plans for
your employer to choose from. We pride ourselves in our endeavor to
help you maximize your benefits, without allowing the insurance company
to mandate the dental services provided to your child. An example of
this would be the suggested provision of topical-application fluoride
during your child’s preventative care visit. Our doctors, the American
Association of Pediatric Dentistry as well as the American Dental
Association recommend topical fluoride for children 2 times per year.
Most insurance companies, however, in an effort to reduce costs, only
allow it 1 time per year. We would not want to cheat your child out of
proper care (and an effort to reduce decay) by not providing fluoride 2
times per year just because the business office of the insurance carrier
has decided to not provide that benefit to you. Instead, our policy is
to inform you of the medical based importance of this recommended
procedure and then allow you to make the decision which best fits your
family’s needs. We believe an informed decision is always a better
decision.
Fact 3 – UNDERSTANDING INSURANCE CLASSIFICATIONS OF “UCR”
You
may have noticed that at times, your dental insurer reimburses you or
the dentist a lower rate than the dentist’s actual fee. Frequently,
insurance companies state that the reimbursement was reduced because
your dentist’s fee has exceeded the usual, customary, or reasonable fee
(“UCR”) used by the company.
What exactly does this mean? A statement
such as this gives the impression that any fee greater that the amount
paid by the insurance company is unreasonable or well above what most
dentists in the area charge for a certain service. This can be very
misleading and simply is not accurate.
We prefer the term “Insurance
allowable fee structure” as it is more accurate and not misleading as
the term “Usual, customary, or reasonable – UCR – is.
Insurance
companies set their own schedules and each company uses a different set
of fees they consider “allowable”. These allowable fees may vary widely
and have a broad basis upon which they are set by the insurance
companies. In most cases, the “allowable” fees are set about 30% below
actual industry standard so that the insurance company can make the
profit they need in order to operate. In general, the less expensive
insurance policy will use a lower usual, customary, or reasonable (UCR)
figure.
Fact 4 - DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED
When
estimating dental benefits, deductibles and percentages must be
considered. To illustrate, assume the fee for service is $150.00.
Assuming that the insurance company allows $150.00 as its usual and
customary (UCR) fee, we can figure out what benefits will be paid. First
a deductible (paid by you), on average $50, is subtracted, leaving
$100.00. The plan then pays 80% for this particular procedure. The
insurance company will then pay 80% of $100.00, or $80.00. Out of a
$150.00 fee they will pay an estimated $80.00 leaving a remaining
portion of $70.00 (to be paid by the patient). Of course, if the UCR is
less than $150.00 or your plan pays only at 50% then the insurance
benefits will also be significantly less.
MOST IMPORTANTLY, please keep
us informed of any insurance changes such as policy name, insurance
company address, or a change of employment.
Does it feel like you need a college degree in
mathematics and logic to figure out your portion of your dental bill,
whose office you can go to, or what procedures are covered by your
policy?
If you answered yes, you are not alone. We receive 100’s of
questions per week relating to these issues and more. Our knowledgeable
staff can help you understand & maximize use of your dental insurance
benefits. It’s important to understand your policy, and the choices
your employer may be giving you so that you can make the best decision
possible in behalf of your dental needs. Following is a guide to the
differences in the major groups of dental insurance policies and
benefits commonly offered to employees.
There are basically 5 groups of
policies available to us all. Most dental insurance providers offer a
choice of policy matching each group. As is true with most things in
life, each policy comes with a different price tag to the purchaser of
the policy (usually your employer). The greater the premium, the
greater the benefits to the members. The insurance carriers may refer
to their policies by various names…for ease of consistency we’ve
identified them under commonly used descriptors:
Traditional Dental
Insurance: This type of policy allows you to go to any dentist in the
country (You do not have to pick from a list of dentists provided in a
book from the insurance company). Most dental offices now offer to
submit your insurance claim for you. For the few who don’t, you can pay
for your appointment in full yourself, then submit the receipt with a
claim form to receive due compensation from the insurance company.
Most dental insurance carriers stipulate an initial deductible to be
paid by the member. (Commonly $50.00). Oftentimes, the deductible is
waived for preventative care (cleanings, fluoride, exams and x-rays).
The ‘deductible’ applies the first time the member uses his/her benefits
for ‘restorative or operative’ treatment (fillings, crowns, root canals,
etc). This means the member would need to pay the first $50.00 of that
treatment.
Most policies are structured to cover a percentage of the
treatment being done, expecting the member to cover the remaining
percentage. Insurance companies have grouped different types of
procedures into 3 commonly recognized benefit levels: Preventative care
(cleanings, fluoride, exams, x-rays and sealants); Basic restorative
care (fillings, simple extractions, children’s pulpotomies [root canals
on baby teeth], children’s stainless steel crowns); and Major
restorative care (adult root canals, adult crowns, bridges, complicated
extractions). As an example of their percentage breakdown of benefits,
they may cover ‘preventative’ procedures at 100% (no cost to the
member), ‘restorative’ procedures at 80% of the proposed fee (leaving
20% to be covered by the member) and ‘major’ procedures at 50% of the
proposed fee (leaving the other 50% to be covered by the member). This
is the most costly policy offered but offers the member the greatest
extent of benefits.
PPO Dental Insurance: This type of policy is
similar to the traditional dental insurance in structure but adds a
choice to the policy holder. The member has the choice of using a
contracted, ‘in-network’ provider or using an ‘out of network’
provider. The difference to the member is usually about a 10%
difference in dental coverage benefits (10% less when going to an out of
network provider). Most dental specialists like orthodontists,
pediatric dentists, oral surgeons, etc do not contract as ‘in-network’
providers so realizing that you can still see the specialists and
utilize 90% of your potential insurance benefits is a great asset. A
lot of larger employers in and around Stapleton, like University of
Colorado, offer PPO plans as one of the choices to their employees.
This is a great choice for all of your family’s dental needs.
EPO
Insurance: These plans mandate that the member use
a dental provider on the list only. We
are proudly one of the few pediatric
dental specialists who have contracted
with all dental insurance companies and
accept these policies. The plan is
structured as a fee schedule instead of
a percentage of fee. That is...your
employer and the insurance company have
negotiated what the plan will cover and
varies per individual procedure. Your
"out of pocket" expense is usually much
lower on these plans than on any other
since under these contracts, the dental
office "adjusts off" a great percentage
of the patient portion for treatment.
The insurance policy usually covers most
of the expense, and the patient is
usually responsible for a much smaller
co-pay. This is also a great choice for
family dental care.
Discount Plan:
This newer concept for dental coverage simply provides the member with a
percentage discount across the board for all dental procedures (for
example 25% off of all fees). The member is responsible for paying the
remaining 75% of their dental bill. There is no deductible and no
claims are filed with an insurance company. The dental office commits
to providing the discounted fee. This is often a great solution for
‘self-employed’ families who do not have access to group dental
insurance. We partner with 2 discount plans: Ameriplan and NHCD.
Fee
Schedule: Unlike traditional insurances which pay a percentage of the
dentist’s fees, a plan that pays on a Fee Schedule pays a nominal, set
dollar amount for each procedure code. Your insurance company will give
you a copy of this schedule upon request. Oftentimes, employers allow
their employees to pick the policy they wish to have, requiring the
employee to pay the difference in the premiums. Weighing your options
becomes an important consideration. Feel free to call our office for a
personal insurance consult to help you pick the policy right for you.
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