Why we like dental insurance?
- Many plans cover 2 cleanings/exams per year at 100%, which enables our patients to have great preventative care and keep smiling.
- Many plans provide partial coverage for restorative treatment that makes dental care more affordable.
Problems with dental insurance?
- Insurance companies make money by the insured paying more in premiums than the benefits they receive.
- As a result, different plans have different stipulations/clauses that limit benefits.
- It is important to know your plan and the limits described in your policy.
- Insurance companies are not the experts in dental care. Though they have stipulations/limits on policy coverage, that does not exclude you from receiving necessary or ideal treatment.
- It is important to not let insurance coverage be the only factor in treatment decisions.
- Sometimes delaying treatment for insurance purposes can lead to more expensive treatment down the road.
Common dental insurance terms
- Maximum: Highest total amount that insurance will pay in a policy year.
- Deductible: Amount that the insured must pay in a year before the insurance company will pay.
- Coverage/Benefit level: Percentage the insurance will pay per procedure code.
- Co-insurance: Percentage of fee that the insured must pay per procedure code.
- Waiting period: Not in all plans but is an initial period that insurance will not pay or limit payment once a new policy is enacted.
- Missing tooth clause: Not in all plans but states that insurance will not pay for replacement of teeth missing before the policy was active.
- Preventative coverage: Typically exams, regular cleanings, and Xrays in most plans
- Basic coverage: Typically fillings but can vary by policy
- Major coverage: Typically crowns, bridges, dentures, implants but can vary by policy.
In-Network/Participating Providers vs. Out-of-Network/Non-participating Providers
In-Network/Participating Providers have a contractual obligation with the insurance company which involves agreement to contractual/allowable fees for services.
Out-of-network/Non-participating Providers do not have a contractual obligation with the insurance company and charge their standard fees for services.
How does an office in-network with my insurance benefit me?
In most cases, you will have lower out-of-pockets costs with an in-network provider since contracted fees are lower than standard fees, and insurance policies often have higher coverage when you use an in-network office.
Why might a dental office choose to be out-of-network with my insurance company?
- Some insurance companies are not reasonable with the fees that are allowed if you are in-network with their policies. Sometimes these contractual fees may be 30-40% lower than standard fees, and offices can struggle to stay in business with such fees.
- If an office takes a 30-40% cut in allowable fees, they are forced to make up for it by doing a higher volume of procedures to stay in business.
- This can create a situation where quality of care takes a dip to accommodate the need for higher quantity of care.
- This can sometimes be noted by rushed appointments or having to use less premium supplies and labs.
- Out-of-network offices can be freed to charge fees that enable them to best promote optimal quality of work by using more premium materials and not being rushed.
Do I have to see an In-network dentist?
Of course not. Though some insurance plans do not have out-of-network benefits, most policies have out-of-network coverage. Our team will be happy to verify your particular plan.
How does our office navigate dental insurance?
- We have taken the time to negotiate with insurance companies to allow us to come to agreeable fees that are reasonable for the time, staffing, supplies, and years of expertise required to do quality dentistry.
- As a result, we are in-network with most insurance companies in an effort to maximize the savings our patients receive through their insurance plan.
- Most importantly, we verify and handle questions regarding our patient’s individual policies to help them better understand their policy and receive accurate financial estimates for treatment.
Contact us at 843-552-4771 and let us help you navigate any insurance questions you may have in order to ensure you receive the best care!