Kim McCrady RDH BS
Dental insurance can be a confusing subject to even the savviest subscriber. Why? They make it confusing for a reason. Dental insurance companies are in business to make money for their stockholders and to pay out as little as possible on YOUR dental claims. Did you know, on average an insurance company has a goal to pay out less than 35% of your total maximum annual benefits? That is roughly $350 per patient per year. That covers routine exams, x-rays and routine dental cleaning twice in a 12-month period of time. The good news is we are here to help you navigate the gauntlet and get your moneys worth from your plan.
1- Know your dental insurance plan. A common mistake is to assume your medical and your dental insurance are the same company. Almost always, this is not the case. Interestingly, many dental insurance companies do not provide you with an ID card. The solution is to ask your HR department. They should be able to provide you with the name and the phone number of your dental insurance carrier. EX:
2- Providing accurate information to your dental office is the first step to getting your claims paid. You will need your subscriber ID number and the subscribers’ date of birth and the patients date of birth. You should know many companies still use your social security number to identify you in their system. If you are uncomfortable with them using your social security number you can request a unique ID number.
3- Know your annual deductible. Almost every dental plan has a deductible they require you to satisfy before they begin to pay out benefits on your dental claims. This deductible can vary in amount. There are usually individual and family deductibles. Family deductibles are often three times the individual deductible. Deductibles can apply to any dental service billed to your insurance company.
4- Many plans do NOT reset your annual benefits in January. You should know your benefit year. This is important so you do not leave unused benefits to the insurance plan. By knowing your plan year, you can maximize your coverage.
5- Your plan has a maximum amount of benefits they will pay on each family member each benefit year. The average maximum benefit is $1500 per year.
6- Although your plan has a maximum amount of benefits per year that are earmarked for your care, the insurance companies pay out your benefits on a percentage scale, NOT at 100% per claim until you have reached your maximum. This scale usually has three categories for dental services:
1-Preventative
2-Basic
3-Major
Each insurance company places dental services into a category. It is important to know how your plan categorizes services so you can better understand you estimated coverage from you dental plan.
7- When your dental office estimates insurance coverage for the dental services you are receiving from the office, it is only as ESTIMATE. Any time you or your dental office call your insurance carrier, the insurance company representatives often read a disclaimer to inform you a description of benefits is NOT a guarantee of payment. It can be very difficult to provide an accurate estimate of insurance coverage. You should expect a down payment for your care and a balance bill after your carrier has processed your claim.
8- Once your dental claim has processed and your plan has paid their percentage of the services to your dentist, you receive an explanation of benefits (EOB). Many people do not even open their EOB’s and read them. They can be very complex, but very informative. EOB’s include the fees billed to your plan for services rendered, payments made by the insurance company on your claim and the patient portion for the services. Often, your plan will include any notes explaining adjustments to payments, including subjecting the claim to frequency limits for services, other exclusions including a feature referred to as down coding.
9- Down coding is a loophole insurance companies have instituted that allows them to pay their contracted percentage on a lesser service. The two most common down coded procedures are tooth colored crowns and tooth colored fillings on back (posterior) teeth. For example, if a tooth colored filling costs $200 and you have 80% coverage on basic services, most plans will not pay the $160. They will “down code” to minimize their responsibility for the services. Therefore, the claim will be received at $200, subjected to your deductible, down coded to a fee for a lesser service, such as a silver filling at $140. Assuming a $50 deductible, the insurance will pay their 80% on $90 instead of $200. This nets a total insurance payment of $72 on your $200 claim and a $128 patient portion.
10- But what if you have a secondary plan to help with your dental claims? Be careful and DO NOT assume your secondary plan will pick up the patient portion for your primary claim. You need to be sure you know if your secondary plan has a “non-duplication of benefits clause”. This means your secondary plan will only pay the difference between what your primary plan covered and what they would have covered if they had been primary. For example, if a claim is submitted for $1000 for dental services to your primary insurance company and your primary covers the service at 50% (assuming the deductible is satisfied and there is no down coding) the primary should pay $500. If you have a non-duplication of benefits clause, the secondary will not pay the patient balance of $500 to complete the claim if, they too, would have covered the services at 50%. But let’s say the secondary plan had 60% coverage for the services rendered and would have paid $600 on the claim. Then they should make payment of an additional $100 so the total insurance payments received between the two plans is equal to the payment they would have made, had they been the primary plan. Secondary insurance often is most beneficial when the primary plan has been maxed out and the secondary begins to pay benefits for care.
In plain English, dental insurance is very different than medical. There are no set co-payments for each office visit. Each visit is considered by your plan once it is received and processed according to the guidelines and limitations of your plan. There are thousands of dental plans with thousands of loopholes and limitations. And it seems the limitations are changing on a daily basis.
Your best bet to successfully utilize your dental insurance coverage is to join forces with your dental office administrators. They spend hours obtaining breakdowns of benefits, applying this information to your care plan, sending the claim with all supporting documentation, following up on the claim weekly to assure payment on your behalf and will often have to repeat the process for you when the insurance company claims to have not received the information. Be kind to them. They are working for you to get you more than the average 35% of your benefits.
Want to learn more? Visit us at http://www.northstapleydentalcare.com/
Where Dentistry is done differently 
