The cost of your treatment may vary depending on your individual needs and treatment plan. We will discuss with you the cost of your treatment and each of your available payment plan options before you begin treatment, so that you can make the best choice for you, your smile, and your family. Your smile is yours forever, and we want to make it as easy as possible for you to receive the best dental care whenever you need it.
Payment Options to help you get the care you deserve. Our practice accepts cash, checks, major credit cards, third party financing with Care Credit and dental insurance plans
Understanding Dental Insurance
Dental insurance is a wonderful benefit and we recognize the important role dental benefits play in improving access to dental care for millions of Americans. Since our practice’s inception in 1967, we have seen dramatic changes to the dental insurance industry. Several decades ago, dental insurance was uncomplicated and easily understood. Nationally, we are now witnessing more confusion and frustration as dental insurance plans are becoming increasingly complex with more limitations and exclusions. As the cost of employer provided insurance premiums have skyrocketed, employers have decreased dental benefits. Consequently, employees now bear a much greater responsibility for the cost of dental care than in years past. Using years of expertise, it is our commitment to provide both the highest quality of care possible AND to obtain the highest level of dental benefits for our patients. We are here to partner with you to help you understand your dental benefit plan.
We have highlighted the most common questions and misunderstandings we hear, to help you understand your benefits better.
“Do you take my insurance?”
“Are you a provider for my insurance?”
“Are you on my insurance company’s list?”
First of all, we would love to see you and will gladly help with all your insurance concerns. We will ask for an estimated co-payment and file your insurance claims for you.
The above questions are best answered by defining the different types of dental insurance 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 insurance 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 insurance benefits, based upon the insurer’s fee schedule. HMO or DMO (Capitation) plans only provide reimbursement if one sees a dentist contracted to provide care at generally a greatly reduced insurance fee schedule.
“How will choosing Phillips Family Dental Care impact my insurance benefits?”
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 insurance 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 insurance will pay.
More and more employers are offering PPO type plans to their employees. Remember, you will still be expected to pay the co-payment for care and any deductible, regardless of who you see.
“Will my insurance cover this?”
Dental insurance is not the same as your health insurance in that it will 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. 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.
Dental insurance companies will often pay for the least expensive treatment option. Downcoding is when a dental plan changes the procedure code to a less complex or lower cost procedure than was reported on your insurance claim. However, the least expensive option is not always the best. An example of this would be if an implant is recommended for you but the plan only covers the less costly dentures. In addition, they often also 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 pay for an implant.
If you have insurance through your employer, then your dental insurance is a contract between your employer and the insurance company. The more you and your employer pay for the insurance, the higher the percentage of coverage and the more procedures that will be covered. We will file your insurance as a courtesy and collect only for any estimated patient responsibility at the time of care.
“How do I find out what my insurance covers?”
Your plan sponsor or human resource 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, insurance 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 documentation.
“If my insurance won’t cover it, is it really necessary?”
Even if a procedure is dentally necessary, it may not be a covered benefit based upon the plan negotiated between your employer and an insurance company. It 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 an insurance 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. Such an example would be when a plan might pay for a teeth cleaning only twice a year even though the patient needs a cleaning four times per year. Make treatment decisions based on what’s best for your health, not just what is covered by your plan.
“I can finally have all my dental treatment done.”
You can and we want to provide it for you. However, most insurance plans have annual reimbursement maximums that haven’t changed since the inception of dental insurance in the 1960’s. Once you exceed your “annual maximum”, no treatment will be covered by your insurance. You need to know whether your “annual year” is based upon the calendar year, your hire date, fiscal year, etc. 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 less than the typically allowable six months, it may not be covered.
“My insurance says it covers 100% for exams and cleanings, but it didn’t pay 100% of the cost of this service.”
Your insurance 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.
“What does UCR mean?”
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 (usual, customary and reasonable) charges 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. Insurance 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, insurance companies are not required to say how they set their UCR rates. Each company has its own formula.
“Why did you send me a bill if I made my co-payment?”
We estimate what your co-payment will be based upon all the information we can obtain from your insurance company and our experience. What your insurance 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 insurance company will not guarantee payment.
“I’ll just wait until next year so my insurance will cover it…”
Don’t delay needed treatment thinking insurance will cover more if you wait until the next “annual year”. We often see patients delay treatment for months and have the treatment become more complicated and costly. These patients ultimately spend more time in the dental office and pay more out-of-pocket than they would have if they had the treatment performed when it was recommended. Let’s talk about your specific needs and weigh the risks of delaying treatment. It is sometimes possible to delay care, to maximize insurance benefits, without necessary risk of the care becoming more costly and complicated.
“My insurance company said they would only pay for the least expensive alternative treatment.”
The “fine print” of most insurance 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 an insurance 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 treatment now may be more costly in the long run.
“I wish my plan covered more of my dental expenses in a timely manner.”
If you have a plan through your employer and you would greatly appreciate a change in the benefit structure, such as a higher maximum, or you have a complaint about the administrator of the plan not processing your claims in a timely manner, talk to your employer or the human resource department. They are 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.
“Why didn’t my secondary insurance pick up the balance due?”
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 examples such as the maximum being met or due to frequency limitations of certain procedures. Each insurance company handles COB in its own way.
“I’m retiring and losing my insurance. Which plan would you recommend?”
“I’m self-employed. Which plan would you recommend?”
“My employer doesn’t offer dental insurance. Which plan would you recommend?”
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 an insurance 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 an insurance company, like a casino, has to be profitable. There are a wide variety of individual insurance plans on the market. We have found no individual plan that would be consistently beneficial in providing excellent care at reasonable premiums. Actually not having a dental insurance plan can allow you greater choice and flexibility. We have many patients that do not have dental insurance. Consider putting that premium dollar to the side to pay for your dental care yourself when needed. We recommend budgeting for dental care expenses similar to how you would budget for regular car maintenance and periodic new tires.
You have a choice. Dr. Phillips has been voted Best Dentist in Sonoma County two years in a row as well as receiving dozens of 5 star reviews making us one of the best dental practices in the area. Choosing a quality driven practice may mean paying slightly more out-of-pocket than choosing an insurance driven practice, depending upon the level of insurance care you and your employer have chosen.
Dental insurance is one part of your healthy mouth plan. We are here to assist you and help you understand your dental insurance plan. Our goal is to maximize the benefits you are entitled to and for you to receive these reimbursements as quickly as possible. If you find out what your dental plan covers and plan accordingly, it can help you have a healthy mouth. We want to help you take the best possible care of your teeth so they will last a lifetime!