Dental insurance. It is unnecessarily complicated, confusing to patients, and frustrating for dentists. Fortunately for you, I have spent a long time learning how it works and training my staff in order to get the most accurate information possible for my patients.
Most dental insurances are what we call category percentage and that is what I will be discussing today. In category percentage plans, for a given category of dental procedure, the insurance will pay a percentage of the fee and the patient is responsible for the difference. Most typical plans pay 100% for diagnostic and prevention (cleanings, exams, x-rays), 80% for basic procedures (fillings, extractions, root canals), and 50% for major procedures (crowns, implants, bridges). The portion that the patient is responsible for is called a co-pay. Some procedures are not covered by certain plans, like dental implants and sedation dentistry.
The deductible is the annual out of pocket expense that must be paid by the patient before insurance will pay. Usually this only applies to Basic and Major categories.
The plan maximum is the total amount of insurance benefit available for the plan period, which is usually per calendar year. This typically starts around $1000 and sometimes can be higher. Once your insurance has paid the maximum benefit, you will have the pay out of pocket for the remainder of the benefit year until your plan maximum renews.
Sometimes a plan will allow you to carry over unused benefits from a previous year. This temporarily raises your maximum so you can receive additional benefits in the current plan year.
Certain procedures may be subject to a waiting period, usually six months to one year. For example, if your plan has a six month waiting period on crowns, you must pay the premium for your plan for six months before you are eligible to use your insurance to pay for a crown.
Missing Tooth Clause
If your insurance has a missing tooth clause, it means it will not pay to replace a tooth that was missing prior to the date the policy was in effect.
This is the frustrating part for most dentists and patients. Sometimes insurance will decide that it will only reimburse the amount for a different procedure than the one that was billed. Unfortunately, this usually results in a higher co-pay for the patient. The substitution rules vary for different insurances, so it is very important to know what they are and how it will affect your benefits.
In-Network Vs. Out-Of-Network
If your dentist is a participating provider with your dental insurance, that means you will receive the maximum available benefit. In-network dentists agree to accept lower fees from your insurance carrier (usually around 20%). That means your co-pays will also be 20% lower if you see an in-network dentist, which can add up to a lot of our of pocket savings. In addition, your annual maximum will go a lot further. What do these dentists get in exchange? Referrals from the insurance company and a well-defined set of reimbursement rules. An in-network dentist should be able to calculate your co-payment very accurately. If your dentist is out-of network, your insurance will decide how much they want to pay and you will be responsible for the difference. Sometimes insurance will pay the same category percentage of the out-of-network fee. Sometimes the insurance changes the percentages, deductibles, and maximums if you see an out-of-network dentist. Other times the dental insurance only pays a percentage of their "Usual & Customary" fee, which basically means whatever the insurance feels like paying. Ultimately this makes giving patients an accurate estimate nearly impossible. A lot of dentists have stopped taking insurance entirely. They simply charge their patients whatever they want and leave it up to the patient to be reimbursed by their insurance.
I can proudly say that I am In-Network with most insurance plans. I believe that cost is important to my patients and I want to give them the best treatment available at an affordable price.
Putting It All Together: Treatment Plans
When a patient comes in and we recommend treatment, we need to accurately calculate how much insurance will contribute and how much the patient is responsible for. Doing this accurately will eliminate any surprise bills at the end of the treatment. In my office, the staff is trained to make every treatment plan as accurate as possible.
Four Different Estimates For The Same Procedure
Let's say you need to have a filling. Fillings are billed by tooth number, surfaces and filling type. In this example we will be doing a two-surface composite resin filling on tooth #13 (ADA Code D2392). This is covered at 80% and the fee is $210. A $50 deductible applies.
Estimate 1: $210-50 deductible= $160. Insurance pays 80% ($128). Patient's co-pay=$82
Often insurance will apply a substitution code for composite resin, paying only the amount for an equivalent amalgam filling. The amalgam fee is $180.
Estimate 2 (substitution code): $180 (amalgam fee)-50 deductible=$130. Insurance pays 80% ($104). Patient is responsible for the difference between what insurance pays and the composite fee ($210-104). Patient's co-pay=$106
In the next two examples we will apply the same calculation but without the deductible. Let's assume you came in for a filling on a different tooth earlier this year. That means the deductible has already been satisfied.
Estimate 3 (no deductible): $210 insurance pays at 80% ($168). Patient's co-pay=$42
Estimate 4 (substitution, no deductible): $180 insurance pays at 80% ($144). Patient is responsible for the difference up to the composite fee ($210-144). Patient's copay=$66
As you can see in our example, for just one procedure there are up to four different calculations that result in co-pays ranging from $42 to $106. Confused? Fortunately we do this type of calculation everyday and can help you to better understand your insurance benefits. If you have questions about your insurance or treatment options, give us a call (617-232-7399) or send us an email (firstname.lastname@example.org).
Dr. Jason Arandia DMD treats dental patients from Boston, Brookline, Brighton, Waltham, Newton and Watertown. He received his general anesthesia training at Hartford Hospital and is licensed to practice moderate conscious sedation and nitrous oxide analgesia. Dr. Arandia is a member of the Dental Organization for Conscious Sedation (DOCS).