Understanding Your Dental Insurance

 

First and foremost, an insurance policy is a contract between the patient and the insurance company only. A dentist has no vested interest nor works for an insurance company.  A dentist’s only obligation as an in-network provider is to accept the maximum fees allowed by the contracted fee schedule.  Nothing more. Dentists are to provide appropriate treatment according to a patient’s diagnosis; not according to what the insurance pays for. Dental insurance does not dictate care nor prevent the dentist from providing services or charging fees not provided on a particular policy. 

 

Secondly, dental insurance is not medical insurance with broad coverage for patients’ injuries or diseases. Dental insurance is merely a “shopping list” of covered procedures/fees negotiated between the employer and insurance carrier; these covered procedures are irrespective of what the patient actually requires.

 

And Thirdly, it is the patient’s responsibility to understand their insurance policy in depth.  We are not required to know, nor have access to the overwhelming minutia of an insurance policy. When we call to confirm eligibility, we are afforded the barest of information; percentages of coverage for preventive, major and minor procedures; frequency of cleanings, x-rays and restoration replacement; and a fee schedule. But the devil is in the details.  These details, unavailable to us, include limitations that may determine waiting periods; pre-existing conditions; non-covered, reasonable and necessary fees; fee bundling; downgrading procedures, even their definition of major/minor procedures. 

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Truly concerned patients can always postpone treatment and request that a pre-determination (pre-d) be submitted to verify what the insurance will cover. And while these can be helpful in making a financial decision, even a “pre-d” is not a guarantee of payment; as the carrier will clearly state in their own response.  We’ve have had several cases that were approved on a pre-d, only to be denied once the treatment was rendered and the claim filed…leaving the patient responsible for the entire fee. 

 

Hopefully, you are beginning to appreciate how dental insurance operates to avoid paying, cause confusion, and drive an adversarial wedge into the doctor/patient relationship. They create perplexing and confusing policies; ambiguously apply limitations or exclusions; don’t honor their own pre-determination approvals; and reserve the right to deem any diagnosed treatment, regardless how obvious, unnecessary and downgrade to a lesser restoration, or simply deny the claim outright.  As you can see, we are totally at the mercy of their capricious behavior in providing our patients a competent estimate of benefits. 

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That notwithstanding, we pride ourselves on being a patient advocate and enjoy a high level of patient satisfaction working with insurance to maximize benefits and reduce unwanted financial surprises. We bend over backwards, tirelessly working behind the scenes on our patient’s behalf; wasting hundreds of manhours a year dealing with insurance company games.

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Regardless, treatment and its inherent financial responsibility are ultimately between the dentist and patient.   By virtue of sitting in my chair and consenting to treatment, patients contractually accept the financial responsibility for all fees associated with that treatment…regardless of your insurance.  We cannot force an insurance carrier to pay; nor are we under any contractual agreement to accept a carrier’s decision of non-payment.  By signing this form, you acknowledge that you must pay for any portion not paid by your insurance, for any reason. Any and all account balances are ultimately your responsibility.

 

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