How are my insurance benefits established?
Insurance is a contract between your employer and an insurance company. The benefits that you will receive are based on the terms of the contract that were negotiated between your employer and the insurance company and not your provider’s office. The objective of most insurance policies is to offer a selection of services that will provide basic care for the insured. The services selected are based on the cost of the policy to your employer and the negotiated arrangements with the insurance company.
Because the benefits you currently have are decided between your employer and the insurance company, you may find that there are many types of services that are not covered under your plan. The selection of non-covered services is not based on what you the patient wants or needs, but is based on the contract that has been made by the insurance company.
What are non-covered services?
The goal of the insurance company is to provide only the negotiated benefits for the specifically selected services in their contract. Unfortunately, some of the services that you may need or want will not be covered by your dental or medical insurer.
How does insurance reimbursement work?
The reimbursement mechanism from your insurance is a mathematical formula. The formula is often times based on something called “usual and customary” rates or “UCR.” These rates can be determined in many different ways. Some insurance companies will use the average fees submitted from doctors in a particular zip code. More often than not, counties, states, or entire regions are used to determine these rates. Many insurance companies do not invest the time, money, and resources necessary to reevaluate their usual and customary rates on a regular basis, leaving the older fees as the base for their calculations. There is no regulation as to how insurance companies determine reimbursement levels, resulting in a wide fluctuation. Some insurance companies will look to Medicare as an base for the level of reimbursement. For many providers, Medicare will reimburse only 10% of the doctor’s fees. So as you can see, there are many determining factors in reimbursement for fees, however, none of them are based on the individual patient and what their needs may be.
Another fact that many insured patients don’t realize is that dental insurance plans have a dollar amount limitation or yearly maximum. Your plan purchaser makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company. Once this limit is reached, no other services will be covered by your dental insurance company, no matter how essential the service may be to your health. Even though the cost of dental care has significantly increased over the years, the maximum levels of insurance reimbursements have remained the same since the late 1960’s. Many plans are beginning to offer higher maximums that are comparable to rising dental care costs.
What is an insurance “pre-determination?”
An insurance pre-determination is a form that can be submitted to your insurance company prior to any treatment. You have the option of requesting that our office submit all of the services that we have treatment planned for you to your insurance company for their consideration prior to having the services rendered. The insurance company will then send back a “pre-determination” of what they will allow for each procedure. Some insurance companies require that a pre-determination be sent prior to treatment, while others merely recommend that a pre-determination be sent in for review for treatment plans over a certain dollar amount.
This process can take anywhere from 4 to 6 weeks. Many times the insurance companies determination does not factor in the patient’s yearly maximum. The insurance company can also put a disclaimer on the determination that states that it is not a guarantee of benefits/payment. Although most reputable companies will honor a written pre-determination, some companies will use this disclaimer as a way to get our of paying the benefits once the services have been rendered.
What is elective treatment?
Elective treatment is treatment that the patient chooses to have done even though it may not be considered “medically necessary.” We want our patients to exercise their choice. Our hope is that all of our patients will base their important medical/dental health decisions on what they want or desire not what insurance coverage will allow.
What is meant by “least expensive alternative treatment?”
Your dental plan may only allow benefits for the least expensive treatment for a condition. For example, your dental provider may recommend a dental implant to replace a single missing tooth, but your insurance may only offer reimbursement for the alternative treatment of a bridge. As with other choices in life, such as purchasing medical or automobile insurance, the least expensive alternative is not always the best option.
How does your office help with insurance?
We understand that insurance can be confusing and frustrating due to its increasing complexity. Our experienced and friendly office staff will do everything possible to help you understand and make the most of your particular insurance benefits. It is our goal to achieve the maximum reimbursement as quickly as possible.
Please be aware that despite our diligent efforts, some insurance companies will take longer than others to complete the payment process. Some companies engage in tactics designed to delay the claim processing and subsequent reimbursement. We work hard to deal with these matters promptly and when necessary, we may request the insured party’s help in the matter.