Insurance
Information & Policies
We have many
years experience in handling Dental Insurance processing so
as to help you receive the maximum benefits to which you are
legitimately entitled.
If one or
more Insurance Companies are to be billed, it is the
patient's responsibility to provide this office with one
fully filled-out and signed form for each company, for each
dependant family member enrolled as a patient. With the
exception of only one or two non-standard insurance plans,
our computer system can generate any further forms needed
during your treatment. However, we MUST have one completed
form for each patient on file to be able to bill your
insurance carrier's).
Also, it
will be extremely helpful in estimating your probable
benefits if you will review your booklet describing your
Dental Insurance coverage which you can obtain from the
Benefits person at your place of employment or from your
union. With most plans, there is an annual deductible and
a co-payment percentage required to be paid by the
patient. In most cases, this can be determined fairly
easily. A Pre-Treatment Estimate form can be sent to
the Insurance Company to determine probable benefits and
co-payment amounts before treatment is begun if you need
this to plan your investment. Realize though that this
will delay treatment, a delay which your insurance carrier
prefers.
Unlike many
other dental offices, we do accept assignment of insurance
benefits, however, when benefits are
"assigned" this way, we do require that you pay
your estimated "co-payment" share at each visit.
Also, if there is an "Annual Deductible", it is to
be paid at the first visit of each new calendar year. You
may choose to have insurance reimbursement benefits sent
directly to you, rather than assigning payment to this
office. In that case, your account will be handled as a
"Private" account, and you will be asked to make
the appropriate Financial Arrangements regarding the full
estimated fee prior to beginning treatment.
For
estimating purposes, we have found from many years of
experience that the actual Patient's Share
"co-pay" amount for Basic Services (such as
routine fillings, basic periodontal/gum therapy, root-canal
therapy, uncomplicated extractions, adjustments and
emergency treatment) is usually about 30% of the "real
world" fee, while for Complex Services (such as Crowns,
Bridges, Dentures and other Prosthetic Services)
"Patient's Share" is usually approximately 60% of
the fee. Diagnostic and Preventive services (such as exams,
x-rays and routine, every-6-months health maintenance
"cleanings" -- NOT "Periodontal
Services" or "Gum Treatments/Initial Periodontal
Therapy") are usually covered at or nearly 100%, so no
"co-pay" is usually required, though there are
always exceptions. Coverage for TMJ treatment is so
variable among carriers that it is impossible for us to know
what they will do.
Almost all
plans have an "Annual Maximum Amount" payable per
covered person per year, usually $1000.00 to $1500.00.
If this is a significant factor in your treatment planning,
you must tell us, and we will do our best to keep within
that limit unless it interferes with your proper care and
would cause you harm. (NOTE: That annual maximum payout
has not increased in over 20 years, while premiums and
dental costs and the price of a loaf of bread certainly
have. Makes you wonder, doesn't it?)
Please
understand you are responsible for any treatment costs not
paid by your dental insurance for whatever reason. Any
amount properly billed to your insurance company that is not
paid by them within the customary 30-60 days will become
payable by you directly, and any payment subsequently
received from the insurance company will be reimbursed to
you.
Our
responsibility is limited to the timely submission of
properly and accurately filled-in claim forms to your
insurance company. If the insurance company messes up, we
will attempt to follow-up on the matter as time allows.
However, since the contract is between you, your employer
or union, and the insurance company, it is ultimately up
to you to deal with any major problems that might develop. YOU
have the "power" with them, not us.
Because (in
my personal opinion) so-called "Preferred Provider
Organizations" (PPOs) and similar "discount"
plans aggressively promoted by some insurance companies in
the name of "cost control" are structured to
encourage lower quality care, to keep their profits up and
artificially lower premium costs, we choose not to affiliate
with any. Stated simply they would have us deliver
less than ideal dental care and we are unable with good
conscious to do this for you or our own family.
The exact
insurance benefits you have are determined by negotiation
between your employer or union and the Insurance company and
depend on the amount of premium your employer or union
chooses to pay. We have NOTHING to do with these
arrangements. We bill out only the services actually
performed and at our current fees charged to all patients
for comparable services. If you are unhappy with
your benefits, we sympathize, but much as we might wish to
we can do nothing about it. You should discuss this with
your employer or your union.
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Fact
Sheet About "Your" Dental Insurance
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Fact
#1-- Dental insurance is not meant to be a
"Pay-All". It is only meant to assist
you in paying for your dental care. If it
truly paid "100%" of "everything",
the premiums would be astronomical.
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Fact
#2-- Many routine dental procedures are not
covered by insurance plans, though they may be
normal and necessary. This may be because the carrier
does not cover the procedure (to save on costs and
protect its profits) or your company did not purchase
that particular coverage, also to save on its costs;
or they may just not be up-to-date on current
practices and techniques. The terms of the plan
coverage have nothing to do with what services you
actually need or what we recommend. This is
especially true of Hygienist Care
("Cleanings") frequency!
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Fact
#3-- Many plans state that you will be
"covered" up to 50%, 80% or even 100% for
various services. In spite of what you're told, sad
experience has shown that in actuality many plans
may cover considerably less than expected,
depending on their established "Usual &
Customary" fee schedule. The benefits your
company plan pays are largely determined by how much
your employer or union chooses to pay for that
particular plan. The less he/it pays in
premiums, the less you'll receive in benefits.
Dental
insurance is not at all like medical insurance. In
many ways it is much more similar to your car or home
insurance. You can buy a car or home policy with no
deductible or a large deductible. It may cover all or
only a variable portion of minimal repair on up to
total replacement cost.
Likewise,
your employer or union can choose from dental policies
that have varying deductibles and varying percentages
of fee "coverage" based on varying methods
of determining their so-called "Usual
& Customary" fee schedule.
You
can save on your car or home insurance premiums by
buying a policy with a higher deductible, and a lower
percentage of "coverage". Likewise, your
employer or union can save on their premium costs by
buying a cheaper group policy with a higher deductible
and/or a lower "annual maximum" payout,
and/or a lower percentage of actual
"real-world" fees covered. If they are
really pinching pennies, they may even buy some form
of cut-rate "managed care" plan that limits
who you may choose as "your" dentist.
Bottom
line is, a lower level group plan may say that
they pay "80%"…but they may not also tell
you that this means 80% of "Policy
Allowance". This really means that they set
an arbitrary "allowed fee" for services that
is "affordable" to the purchasing employer
or union, and keeps the insurance company at the
profit level they want. Then they pay 80% of that
"allowed fee" that they set, regardless of
the actual cost. On top of that, if their allowance is
for the "70th percentile level" (something
else that may only be mentioned in the very fine
print) they may actually pay only 56% (70% of the
supposed 80%)!
Now
that is still not a shabby benefit. Your employer is
paying for over half the cost of your personal dental
care (up to whatever annual maximum has been
designated).. That can represent a significant
"out of pocket" saving to you. On the other
hand-- it is not 80% and should not be the determining
factor in making health care decisions for someone who
wishes to be as healthy as can be.
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Fact
#4-- An insurance company's established
"Usual & Customary" fee schedules may or
may not accurately reflect "real-world" fees
for a given area. Each company establishes its own
arbitrary version of "Usual & Customary"
fees. Therefore it often happens that different
insurance companies will have different "Usual
& Customary" figures for the same
geographical area. A dentist's fee for a procedure
could be well within one company's "Usual &
Customary" schedule -- and not in another's! It
has been the experience of many dentists that some
insurance companies tell their insured that
"these fees are above the Usual & Customary
level", rather than tell the truth of the matter,
"their benefits are lower than they should
be". The sad fact is that most group dental
insurance benefits and annual limits have not even
kept pace with general inflation over the past
twenty-something years -- and groups purchasing
coverage are getting much less for their premium
dollars than they used to. and as a result you the
patient receives less benefit.
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We
thought you might find these facts interesting.
Though
our fees in many cases may be somewhat higher than
"average" or "clinic"-type fees
(because we don't provide "average"
dentistry or "clinic"-type service) they are
more than "reasonable" for the kind of care
we believe you want to receive. In most cases you will
find that your insurance will cover a sizeable
percentage -- often half or more -- of your actual
total treatment costs. Keep in mind that when we
make treatment recommendations, we do so with the
thought of making you as healthy as we can - the same
suggestions we would make for a family member.
Treatment plans are designed without regard to if you
have insurance or not, since this issue has more to do
with you planning your financial investment than it
does determining your actual health care needs.
Our
office will assist you as much as possible in
obtaining the maximum benefits you are legitimately
entitled to. In the event of major reconstruction-type
treatment, where possible we will "phase"
the treatment over two or three years if necessary, to
coincide with benefit years and such, and minimize
your "out of pocket" share. We've been doing
this for years, and we know the ins and outs. And
we'll help you with your share by setting up a
workable Budget Plan if you wish. (But please don't
ask us to "fudge" treatment dates, or
"write-off" your required co-pay share.
Those maneuvers are considered to be fraudulent and
unethical. They are also illegal and are a
"No-No" under any circumstances. Yes
people have asked us to do this.)
Remember
-- you only get back from your insurance what your
employer or union puts in, less the operational costs
and profits to the insurance company. Insurance
companies are not charitable organizations. They are
not in the business of caring for your health or good
looks. They are not "objective" or
"non-partisan". They do not know your dental
needs, nor do they care except insofar as that
information might affect their bottom line. Their
primary purpose is making money, just like every other
financial business. Their number one priorities are to
make a profit and cut expenses -- by paying out the
absolute minimum in benefits and by collecting the
absolute maximum in premiums. (In my personal opinion,
so-called "managed care" PPO/HMO plans
appear to be the worst of the bunch, designed
primarily for the enrichment of the insurance
behemoths.)
OUR
business is helping you maintain and maximize your
long-term dental health, comfort and function.
We will always urge you in the direction of health and
we will always encourage you to take action now with
respect to getting healthy.
Our
number one priority is YOU.
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As you are
perhaps aware, health care is undergoing a radical change in
the United States. Unfortunately, this often means fewer
choices for patients. Many insurance plans now dictate who
your physician or dentist will be -- whether you want that
choice made for you or not.
In the next
few years, many of you will have the opportunity to select
which type of dental plan you would like to join. At the
time of this selection, you will want to be very careful to
make sure that you make an informed choice about who
provides your dental care. Insurance plans that restrict the
dentist that you may choose to a list of "preferred
providers" (PPOs and PDOs) usually have negotiated
significantly lower fees with those dentists for
"members" of that managed care plan, generally
using the inducement of "increased numbers of
patients" resulting from participation in their
cut-rate plan. This results in a lower level of
client-patient service and fewer options in scheduling
appointments, and may even affect the type of care you are
offered and provided. (It is difficult to provide
high-quality services at lower than break-even remuneration
levels…)
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Invisible Orthodontics
