Dental Insurance: The TRUTH

Posted by Dr. Joanne Baldos and Dr. Adam Szymczak on Jan 18, 2023 7:30:00 PM

Q: Will my dental insurance cover the dental work?

This is the most common question we get asked regarding dental insurance.

 

Most people think they know what dental insurance is, but they have many misconceptions about it. Unfortunately, these misconceptions sometimes lead to misunderstandings with the dental insurance company, your employer or your dental office.

Dental insurance is a contract between your (or your spouse's) employer and the insurance company for your benefit. 

 

Your dental insurance coverage depends on the following:

  • how much your employer is willing to pay toward your coverage
  • what your employer negotiated with the insurance company 
  • the more your employer is willing to pay, the more dental coverage you have

 

Your dental insurance coverage is NOT determined by what you may need or want! 

 

Your dental insurance and your employer do NOT know your oral health.

 

Which dental procedures are covered and at what % under your dental insurance policy has very little to do with your particular oral health situation.

 

We, as a dental office, know your dental and general health. We understand your needs and wants and ALWAYS act in the best interests of your health and well-being.

 

We do not know what your insurance covers and what it doesn’t cover.

 

The insurance information you provided allows us to submit your dental claim to the insurance company on your behalf; it does NOT allow us to see what the dental insurance will cover.

 

We are happy to help you get to know your dental insurance coverage so that you can figure out how much coverage you are entitled to.

 

 

 

Q: What should I know about my dental insurance?

Knowing your dental insurance will give you peace of mind and prevent unexpected dental bills.

 

Your dental insurance is not free! You pay for it indirectly. Your employer could be directly giving you the money they are spending on your insurance. Knowing your dental insurance will give you peace of mind and prevent unexpected dental bills.

 

Your dental insurance is a contract; hence what is covered and not covered is preset. Therefore, there is very little influence over the dental insurance company concerning your coverage.

 

The critical information that you need to know about your dental insurance:

 

1) What is the yearly maximum? 

Most dental insurance plans will only pay out up to a certain maximum in a 12-month period. Once that limit is reached, all further dental claims will be denied!

 

2) What is the “insurance year”?

The 12-month period in which the "yearly maximum" applies is NOT necessarily a calendar year! So find out when your "insurance year" is, in other words, which 12-month period the yearly maximum applies to.

 

3) What % coverage do you have for “minor work”?

"Minor work" is basic dental work. For example, most dental insurance companies include the following under "minor work": exams, x-rays, cleanings, extractions, fillings, and root canals.

 

4) For "major work," ask us to send an estimate to the insurance company IF the level of coverage will influence your decision to proceed with the treatment. 

 

5) Even though you may have been with the same employer and insurance company, do NOT assume that your dental insurance is the same. Employers and insurance companies re-renegotiate the policies frequently!

 

We would love to figure out and keep track of your specific dental insurance coverage on your behalf. However, it is impossible for us to do because there are thousands of different insurance plans which frequently change.

 

We know the commonalities that insurance plans share and can guide you in figuring out your dental insurance plan. You should be familiar with your dental plan as you are responsible for paying the balance not covered by the insurance company.

 

 

Q: Why did the dental insurance NOT pay for my treatment? 

Dental Insurance: Why did the dental insurance not pay?    

 

When something is not covered, or it is not covered fully, it means that your employer did not negotiate in the insurance contract for that to be covered.

 

Insurance benefits originate when the employer sets a specific budget for employee benefits, shops around different insurance companies, and negotiates what will be covered.

 

Therefore, what is covered or not covered has little to do with what a specific patient may need or want! 

 

A common misconception is that what is recommended by the dentist should be covered. The truth is that what is or is not covered has nothing to do with the patient; it has to do with what the employer and insurance company have negotiated. 

 

Some patients have negative feelings towards insurance companies because something is not covered. The truth is that most people without dental insurance do not go to the dentist. Dental insurance is a blessing to a patient's dental health!

 

It is helpful to think of dental insurance as a way to help you pay for dental treatment you may need or want.

 

To the insurance company, a patient is just a number, a business transaction, a contract, nothing personal. A hypothetical situation: a dental insurance company doesn't care if a particular dental procedure were to save your life; they will not cover it if it is not in the contract.

 

Dental insurance HELPS you pay for your dental treatment. However, it only covers the cost of some dental treatments you could benefit from. If the insurance company does not pay for recommended treatment, avoid getting upset with the insurance company; chances are you would not get any dental treatment if you had no insurance.

 

We are your dental health advocate and always have your best interest in mind. But, unfortunately, to the insurance company, you are just a number.

 

 

Q: What can I do to prevent unexpected dental bills?

Dental insurance and unexpected dental bills

 

Get to know your dental insurance plan (see above) and ask for an estimate to be sent to the dental insurance company.

 

We understand the surprise that comes with having an unexpected dental bill due to dental insurance not paying as expected. As such, upon patient request before the treatment is rendered, we can submit an estimate to the insurance company so that the patient can better understand what the insurance will cover and what the patient will have to pay. 

 

Sometimes the amount you are responsible for differs from the estimate because amongst other reasons:

  • The insurance may have changed from when the estimate was sent.
  • The most important information is in the details; read the fine print in the estimate especially plan limitations such as insurance maximums.
  • The dental fees may have changed since the estimate was sent.
  • On some occasions, the treatment may differ from the estimate because: 
    • With time, the condition that requires treatment changes.
    • New information about the condition is discovered at the time of treatment, requiring a change in the treatment provided.

 

The dental insurance response to an estimate is sent to the patient, not the dental office; if you book an appointment, we assume you are aware of your financial responsibility.

 

 

SUMMARY:

  • Our policy regarding dental insurance has remained the same since 2001.
  • We ALWAYS act in the best interests of your health and well-being.
  • Our recommendations are based on what will benefit your health.
  • We do not know what your insurance covers and does not cover.
  • We are happy to assist you in better understanding your own dental insurance. 
  • For your convenience, we submit your dental claim to the insurance company on your behalf.
  • For your convenience, we accept payment directly from the insurance company; however, any amounts not paid by the insurance company are your responsibility to pay us; payment in full of any patient portion is due the day of service.
  • A dental bill needs to be paid in full regardless of insurance coverage.

 

Please note that the above policy applies to all patients.

 

Thank you for choosing Smile Care Dental for your dental care. We pride ourselves on developing long-term relationships with our patients based on compassion, integrity, trust, respect, open communication, and excellent dental care and service.

In the best interest of your health and well-being

In the best interest of your health and well-being,

Dr. Joanne Baldos and Dr. Adam Szymczak

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