Financial Information

First of all, we would love to see you and will gladly help with all your dental plan concerns. We will ask for an estimated co-payment and file your dental plan claims for you. Your questions are best answered by defining the different types of dental plans first.
Indemnity Dental Plans allow you to see any dentist with equal reimbursement regardless of whom you see.
Preferred Provider Organizations (PPOs) are dental plans that have contracted with dentists who agree to accept the PPO dental plan fee schedule as a financial incentive for patients to select their practice. Contracted dentists are considered "in network" and on their provider list. PPOs allow patients to see "out of network" dentists and use their dental dental plan benefits but there may be a higher fee. This varies among the dental plans, so you will need to learn the details about your plan. Also, keep in mind that "Preferred" in PPO does not reflect the dentist's expertise or experience. It simply means that dentist in "in network".
HMO or DMO (capitation) plans only provide reimbursement if one sees a dentist contracted to provide care at generally a greatly reduced dental plan fee schedule. Just remember, this type of plan may involve corporate dentists who don't guarantee their work. Make sure you're seeing a highly experienced dentist.

The level of reimbursement you receive is based upon what you and your employer pay as premiums, and you have a choice of whom delivers your care. We are not on any "list" and have one fee schedule for all our patients regardless of dental plan coverage. This allows us to remain a quality-driven practice and make recommendations based upon what is in the best interest of our patient's health, not on what a dental plan will pay.
More and more employers are offering PPO type plans to their employees. With this type of plan, you can choose any dentist for your care. Remember, you will still be expected to pay the co-payment for care and any deductible, regardless of the dentist you see.

A dental plan is not the same as your health insurance. A dental plan will not cover all necessary care. Dental plans are designed to help defray the costs of dental treatment, not pay for dental care. Typically, plans cover varying percentages of treatment, but not necessarily all treatment. Nearly all dental plans have an annual maximum benefit limit, regardless of your dental needs. Your annual benefits limit may be based upon a calendar year, fiscal year, or an enrollment year. Individual dental plan Dental plan companies will often pay for the least expensive treatment option. However, the least expensive option is not always the best. In some cases, we have seen a dental plan actually change the procedure code we put on your claim. They will change it to reflect a less complex or lower-cost procedure than you actually had -- covering the cost of a stainless steel crown instead of a porcelain crown, for example. When this happens, your coverage of your actual procedure will be much less. In addition, dental plans often have a pre-existing condition clause. A dental plan may not cover conditions that existed before you enrolled in the plan. For example, if a tooth was extracted prior to the effective date of the plan, they will not provide benefits toward an implant. Employer plans If you have a dental plan through your employer, then your dental plan is a contract between your employer and the dental plan company. The more you and your employer pay for the dental plan, the higher the percentage of coverage and the more procedures that will be covered. We will file your dental claim as a courtesy and collect for any estimated patient responsibility at the time of care.

Your plan sponsor or human resources department should provide you with information that defines co-payments, exclusions, limitations, and annual maximums. We will gladly help ascertain this information for you. Regardless of who provides the information, dental plan companies stress that the information provided is subject to professional review and is only an estimate. Benefits are determined when a claim is received along with all of the requested supporting documentation.

Even if a procedure is dentally necessary, it may not be a covered benefit based upon the plan negotiated between your employer and a dental plan company. A denial from your dental plan company does not mean that the services are not necessary. Treatment decisions should be made by you and your dentist. We will always recommend treatment based on your needs, not on what a dental plan company will or will not cover. For instance, a dental plan may limit the number of times it will pay for a certain treatment. But some patients may need a treatment more often to maintain good oral health. For example, some people need a cleaning four times a year. The plan may cover only two cleanings per year. Your teeth are valuable. You should make treatment decisions based on what's best for your health, not just what is covered by your plan. Dr. Phillips will advise you on treatment that is best for your situation.

You can and we want to provide it for you. However, most dental plans have annual reimbursement maximums that haven't changed since the inception of dental plans in the 1960's. Once you exceed your "annual maximum", no treatment will be covered by your dental plan. You need to know whether your "annual year" is based upon the calendar year or fiscal year. This is an important consideration for us, as we want to help you maximize your benefits. Likewise, many plans have "frequency exclusions" that you need to be aware of. If you have your teeth cleaned even one day prior to the typically allowable six months, it may not be covered.

Your dental plan company pays 100% for the service provided up to the arbitrary limit they have set with your employer. They will pay 100% of their limit, not what your dentist or any other dentist in your area may actually charge for this service. Again, the more you and your employer pay for the plan, the greater the reimbursement level.

All services under your plan have a "covered expense", "maximum allowable", "usual", "customary" or "reasonable" fee that your dental plan uses to base coverage upon. UCR stands for "usual, customary and reasonable" charges which are the maximum allowable amounts that will be covered by the plan. Although these terms make it sound like a UCR charge is the standard rate for dental care, it is not. The terms are misleading for several reasons. Dental plan companies can set whatever amount they want for UCR charges. They may not match current actual fees charged by dentists in a given area. A company's UCR amounts may stay the same for many years. They do not have to keep up with inflation or the increased costs of providing dental care. In addition, dental plan companies are not required to say how they set their UCR rates. Each company has its own formula.

We estimate what your co-payment will be based upon all the information we can obtain from your dental plan company and our experience. What your dental plan company considers the "covered expense" or "maximum allowable" fee is proprietary information they will not share with us. The only way to obtain the exact allowance for care is by submitting a Pre-treatment Estimate before treatment is initiated and then wait for a response and even then your dental plan company will not guarantee payment.

Don't delay needed treatment thinking your dental plan will cover more if you wait until the next "annual year". We often see patients delay treatment for months -- but during that time, their dental problem has worsened, so their treatment will be more complicated and costly. They will also have more dental visits to get the treatment. If they had simply had the treatment performed when it was recommended, the treatment would have been simpler and they would have paid far less out-of-pocket. That being said, it is sometimes possible to delay care, to maximize dental plan benefits, without necessary risk of the care becoming more costly and complicated. Let's talk about your specific needs and weigh the risks of delaying treatment. Dr. Phillips is really good about helping patients prioritize their care. He can help patients plan their care over five years or longer so they can budget for it. Dr. Phillips understands that dental work can be a strain, and will always work with you to prioritize and plan sensibly.

The "fine print" of most dental plans allows them to substitute and pay only for the least expensive treatment alternative. Again, this is an issue of the contract negotiated between your employer and a dental plan company, based upon the costs of the plan. As with many things in life, the least expensive may not be the best. Over the period of your lifetime, the least expensive dental treatment now may be more costly in the long run.

If you have a plan through your employer, talk to your human resources department. Voice your desire for a change in the benefit structure, such as a higher maximum. Voice your complaint about the administrator of the plan not processing your claims in a timely manner. Your employer is not going to know your frustrations if they are not told. With knowledge people can make change. While you're at it, be sure to also show your appreciation for the gift of the dental benefits that they have already offered.

Coordination of Benefits (COB) or Non-duplication of Benefits are terms applied to patients that are covered by more than one dental plan. The benefit payments from all insurers should not add up to more than the total charges. Even though you may have two or more dental benefit plans, there is no guarantee that all of the plans will pay for your services. Sometimes none of the plans will pay for the services you need due to the maximum being met or due to frequency limitations of certain procedures. Each dental plan company handles COB in its own way.

We are often asked which individual dental plan we recommend. Here's what we have experienced. Similar to group plans, individual plans have deductibles, frequency limitations, exclusions and a maximum but they most often also have a waiting period for certain procedures of up to 12 months or more. In addition, we are finding more and more individual plans that have a very low Maximum Allowable leaving a greater out-of-pocket than predicted. Because a dental plan company's Maximum Allowable is proprietary, we are not allowed access to the special fee schedule. To get a closer idea as to what an individual plan will cover, we recommend a pre-treatment estimate. In essence, having an individual plan is like gambling; at some point you may be ahead, but a dental plan company, like a casino, has to be profitable. There are a wide variety of individual dental plan plans on the market. We have found no individual plan that would be consistently beneficial in providing excellent care at reasonable premiums. Actually, you can have greater choice and flexibility by not having a dental plan. Many of our patients do not have a dental plan. Instead of paying premiums on an inadequate dental plan, consider putting the money in a savings account. Invest it. Use it to pay for your dental care yourself when needed. We recommend budgeting for dental care expenses similar to budgeting for regular car maintenance and new tires.