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Important Dental Insurance Information For Our Patients -

An Honest Discussion

You're ready to get that Paradise Smile, and we're excited for you and with you! We want your experience here to truly be a DAY AT THE BEACH! With that in mind, we want to openly discuss dental insurance benefits.

Here are some dental insurance topics we wish to discuss:

What is Dental Insurance?

Back in the 1970's, the dental association and the insurance companies developed a coding process to file claims for procedures performed in the dental office. There are literally hundreds of procedures that dentists perform in the dental office, and until then, there was no way to categorize them.

The insurance industry broke all dental services into ten major sections, and each section has dozens of four-digit codes. Over the years the codes have been modified, replaced, deleted, or added. With the advent of HIPPA regulations in the 90's these codes are mandated to be reviewed every two years and all insurance companies are required to accept the updated codes (but not required to pay for them!)

For example, when you present to the dental office for a check-up, that is categorized as a Diagnostic procedure. Your insurance company will normally pay for a check-up twice a year, and "usually" will pay it in full - "usually" being the important word here. Time to discuss "UCR"....

What is UCR?

UCR stands for "Usual and Customary Reimbursement". The UCR is what the insurance industry considers the "average" fee for a particular service performed in a dental office (in a particular part of the country). A UCR is an arbitrary monetary reimbursement fee for a procedure. For example, perhaps the UCR for a tooth-colored filling on a back tooth on just one surface of that tooth (code D2391) is $75. That's fine and good... for the insurance company. Maybe not so good for you the patient, or for us the dental office. Why?...

Doesn't the Insurance Company Work for Me????

Does Walmart work for you? Does Best Buy? Does Microsoft? Nah!!!You know as well as I do that these companies are in business to make a profit for their stockholders. Bottom line: it's business.

Insurance companies are in business to make a profit for their stockholders. Plain and simple. The services we provide and the fee you are charged for that service are rarely what the insurance company wants to reimburse you for! Back to that earlier example of a tooth colored filling: The insurance company "allows" a UCR of $75. That really means that they figure that their stockholders can afford to reimburse the dentist $75 and no more.

When was the last time you paid $75 for a filling? Maybe 1985... a quarter century ago! Most dentists will charge about $100 or more for such a filling. You will be asked to pay for the balance due, as part of service that you were provided.

Who's responsible for the difference?

Dental insurance is a benefit provided to you by your employer. In essence (and in legal terms) this is a contract between the insurance company and your employer to provide you with dental benefits. There is no contract between you and the insurance company or between the dentist and the insurance company.

When there is a balance due on your bill, you will be asked to pay for that difference, since it is your responsibilty to do so. Normally, this amount may be nominal, but on occasion this balance may be considerable. We'll talk more about this later. The important thing to remember is that your dental insurance rarely pays your bill in full(remember, they have stockholders to protect!)

What Are Co-Pays?

Some dental services like check ups, cleanings, and x-rays are important and basic types of services. Most of the time there is 100% coverage on a UCR, which means that if the UCR fee for a cleaning is $50 then they will pay the $50.

Other dental services may be less "basic". Suppose you need a denture, or a crown, or a root canal. These are considered "major" dental procedures and are rarely covered at 100% by your insurance company. These procedures will tell you up front that they are requiring you to pay the difference in the UCR payment...they're asking you to make the "co-pay". A crown, for example, may be payable at 50%. So if the insurance UCR for a crown is $500, they will pay $250 and ask you to make the Co-pay of $250. But....When did you last see a crown cost $500? Maybe twelve years ago?? Again, that UCR! You're gonna see a crown nowadays charged out around $800. That means your insurance company is paying 50% of a UCR that is probably 30% under the true cost of the crown. In our example, of the $800, you'll end up paying ($800-250 =)$550!

Should I Buy Dental Insurance?

The truth? NO!!!!!! Again, it's basic business. If you hire someone to manage your finances then you have to pay that person for their services. You buy dental insurance, and pay them a $100 premium to manage your money, then MAYBE you'll get back $80 in benefits. The difference is their basic overhead cost.

What should you do??? I have always advocated for those who don't have dental insurance that they budget and save for their dental services. I'm human too and it's hard to stick to a budget, but there are ways out there to save for a rainy day, or a dental or medical emergency.

One attractive way to do this is with a Health Savings Account. An HSA is a tax-free savings account that you can use to save for medical (and dental) expenses. The catch here is you need to be enrolled in a high-deductible health insurance plan. Here's a link to give you an excellent discussion about HSA's:

Pros and Cons of an HSA

Yearly Dental Insurance Maximums

Each year that you work for your employer the insurance company makes dental coverage available to you. This coverage almost always has an upper limit of eligibility, or a "Maximum". Sample eligibility maximums may be $750, $1000, or $1500 per year. These maximums usually renew on a calendar basis, which means that you get this benefit every January first.

Some dental insurance plans work on a "fiscal" year, which means that you get this benefit each year on a specific day other than January first. This could be June 1, September 1, etc.

It's important towards the end of the year to plan for the renewal of your dental insurance benefits, so that you can best utilize your insurance maximums. If a treatment plan is presented to you from the office which requires perhaps $2500 of treatment, and you have $1500 in benefits annually, you will want to use $1500 in the end of one calendar year and use $1000 from the next calendar year. We see this usually in upper and lower partial denture cases, for example. We can charge out one partial in the end of the year and the other partial beginning the next.