Our pediatric dental services are considered “out of network” with most PPO plans. Please check with our front desk staff for detailed information on whether our services are considered in-network with your particular plan. It is our pleasure to submit your claims electronically. In order to do this we need all pertinent insurance information by your child’s first appointment. If you do not have the insurance information, you will need to pay for services rendered that day and your insurance company will reimburse you. Please note that we will file your insurance for you and follow up on claims for 60 days.
After this point, following up on claims and paying the remaining balance becomes your responsibility. We ask that you realize that we do NOT work for an insurance company. Rather, we work 100% for our patients. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract. However, the treatment we recommend and the fees we charge will always be based on your child’s individual needs, not your insurance coverage. We file insurance as a courtesy to our patients. It is important for you to be familiar with your insurance benefits. We are more than happy to assist in estimating treatment plans for your child, but remember they are only estimates.
Many parents ask us what is the difference between being “in-network” and “out-of-network.” “In-network” dental providers have contracted with your insurance company to accept certain negotiated (i.e. discounted) rates. Typically the out of pocket cost is lower with an in-network provider. “Out-of-network” providers have not agreed to the discounted rates. It is up to you to determine whether a doctor is in-network with your insurance plan. Keep in mind that accepting your insurance and being “in-network” are not necessarily the same thing. A doctor may accept your insurance and submit claims on your behalf, but that does not mean that he is an in-network provider for your particular plan. The best way to check is to call the customer service number located on your insurance card to verify a provider’s network status. Our office treats patients based on the guidelines of the American Academy of Pediatric Dentistry and every patient’s treatment recommendations are made based on these guidelines, not the guidelines of your particular insurance plan. We see many patients with both in and out-of-network plans because of the quality of care our team provides.
The top three misunderstood facts regarding dental insurance are:
- NO INSURANCE PAYS 100% OF ALL PROCEDURES – Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage or the type of contract your employer has set up with the insurance company. There are literally thousands of contracts available for employers to choose from.
- BENEFITS ARE NOT DETERMINED BY OUR OFFICE – Insurance companies set their own schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR Fee. Frequently this data can be three to five years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit. You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (“UCR”) used by the company.
A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate.
Unfortunately, insurance companies imply that your dentist is “overcharging” rather than say that they are “underpaying” or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.
- DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED – When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less.
What About Finances?
Payment for dental services is due at the time treatment is provided. Every effort will be made to provide a treatment plan that fits your timetable and budget, and gives your child the best possible care. We accept cash, personal checks, and all major credit cards. For more extensive procedures, a payment plan can be set up through Care Credit, or Lending Club –independent finance companies that allow for monthly payment plans.