Why doesn't my dental insurance pay for all costs associated with my dental treatment?
Dental insurance is not really insurance at all. Insurance pays based on a negotiated contract to cover the cost of a loss. Dental insurance is actually a benefit provided by an employer to help their employees pay for routine dental treatment. The employer usually negotiates a plan based on the benefits provided and the cost of the premium. Most plans are designed to cover only a portion of the cost associated with dental treatment.
But my plan says that certain procedures are covered 100%.
That 100% is what the benefits carrier allows as payment towards a procedure, not what your dentist, or any other dentist in your community, may actually charge.
Then, if my plan does not really cover procedures at 100%, why does it say it will?
Benefit plans are often intentionally difficult to understand. Most carriers refer to the payments they allow as the UCR, which stands for "Usual, Reasonable and Customary." Benefits carriers use the UCR method to deceive plan members into thinking that their dentist is charging more than what is actually usual, reasonable and customary. This negative jargon usually does not mean what it actually appears to represent. Your employer and the benefits company negotiate the UCR, and it is a maximum benefit allowed for each specific procedure. These benefits are related to the employer's cost of premiums and the community where you will be receiving dental treatment. The employer has likely selected an allowed benefit, or UCR, that corresponds to the premium they are willing to pay.
Since the payments are negotiated, does this mean that there will always be a balance left for me to pay?
Typically, preventive procedures, such as cleanings, x-rays and routine check-ups, are covered in their entirety because it is more cost effective for the insurance company to maintain dental health rather than to repair dental neglect. On other non-preventive procedures, such as fillings, crowns, extractions and dentures, the benefit company will usually cover only a portion of the expense. Remember that even if a benefit plan does not cover the majority of the cost of the treatment you need, it will still cover a portion and reduce your personal out of pocket expense.
I received an "Explanation of Benefits" from my benefits carrier that states that the cost of my dental treatment exceeds the "usual, reasonable and customary." Does this mean my dentist is charging me too much?
Remember that "Usual, Reasonable and Customary" is actually the benefit that the employer and the insurance company have negotiated as the maximum payment for a particular treatment. It is usually less, and sometimes much less, than what any dentist in your community might actually charge. It does not mean that your dentist is charging too much.
Why is there an annual maximum for my benefits?
Plan maximums limit the amount a benefit carrier has to cover each year. Despite the fact that the cost of dental treatment has steadily increased due to advances in technology and materials science, annual maximums have remained fairly constant since the 1960's.
Why does my benefit plan only pay toward the least expensive alternative treatment?
Many dental plans will only allow a benefit for the least expensive treatment method to save money. For example, your dentist may recommend a crown, and your plan may only provide benefit for a filling. This does not mean that that you do not need the crown or that you have to accept the filling. The dentist is responsible to prescribe what is best for you, while the benefit carrier's responsibility is to make a profit through controlling payments. In this case, at least some benefit will be paid, but more of the expense will be your responsibility.
Why does my benefit plan only pay for a certain number of procedures, like cleanings, x-rays or exams, each year?
Your plan contract specifies the number of procedures it will consider annually, and some procedures, such as certain x-rays, are only covered once over a period of years. It limits the number of these treatments because these are the types of procedures that many people need regularly.
My insurance plan does not go into effect until next month. Why can't my dentist perform the treatment now, and wait until I have coverage to send the claim?
State laws regulate these issues. Legally, it is insurance fraud to change date of services on a claim. Both the patient and the dentist can face legal prosecution.
Why doesn't my dentist participate in my dental network plan?
Most plans require that network dentists observe restrictions to treatment, and in most cases require the dentist to see many more patients per day. Quality minded dentists are uncomfortable with this, as most prescribe to the idea of quality versus quantity when it comes to patient care.
What should I do if my benefit carrier will not pay for treatment my dentist and I think should be covered?
Because your benefit coverage is between you, your employer and the benefit provider, your dentist does not have the authority to make your plan pay. You are responsible for any amount your plan declines to pay. Dentists can write an explanation and send x-rays to benefit providers to demonstrate the medical necessity of treatment. However, the benefit provider may still reject the claim. Sometimes a plan may pay if the patients submit the claims for themselves, but this requires the patient to pay the dentist the entire amount up front and be reimbursed by the benefit carrier. The employer's human resources manager may also be able to help. If a patient is still dissatisfied, they may file a complaint with the state insurance commission through the following link: https://www.doi.sc.gov/Eng/Public/Consumer/conscompfrm.doc.