Insurance Information
As a patient receiving periodontal care in this office you may have questions about the coverage provided by your dental insurance plan.
Members of our staff, who are familiar with dental insurance, may be able to answer some of your questions. Since individual plans offer special coverage's and restrictions, they may not be able to provide you with all the answers.
If our staff can not help you, you may contact:
1. The personnel office at your company.
2. The insurance benefits office at your company.
3. The designated office or representative, as described in the dental insurance plan booklet provided to you by the company.
The insurance booklet should indicate what dental services are covered, what benefits will be paid to you and the dollar amount you will be required to pay. Some insurance plans pay a set amount for a service (a table of allowances) while others pay a percentage (50% to 90% co-insurance) of the fee charged by the dentist. Many policies require that you pay the first $25.00 to $100.00 of the dentist's fee (a deductible) each year and others set a limit on the amount of benefits they pay annually or in a lifetime.
You should read the insurance booklet thoroughly and be sure to ask questions of your company's representative so that you do not have any SURPRISES in meeting your periodontal treatment obligations.
Responsibilites
Your dentist and his professional staff are responsible for treating your periodontal problem appropriately. Treatment recommendations are NOT based on whether or not you have insurance, nor is treatment altered to fit the benefit paid by your dental insurance. Another responsibility, as a service to our patients, is to provide a reasonable amount of information required by insurance companies.
You will be provided with a complete description of the treatment plan with an estimate of the total fee. If you undertake this treatment, you will be responsible for payment of this fee regardless of your dental insurance benefits. Our office staff will discuss with you a payment schedule of which we may both be comfortable.
If, during the course of treatment, we find that additional services might be needed for your care, we shall discuss these with you and their additional cost.
If your dental insurance requires a pre-treatment estimate, our office will assist you by preparing this form. It is your responsibility to see that the form is delivered to the proper person at your place of employment or insurance company if you are required to do so, otherwise the forms will be sent from our office directly to your insurance company.
Limitations of Dental Insurance
Dental insurance, in fact, is not insurance in a true sense. Insurance, such as life, auto and household, is based on the likelihood that death, accident, fire and theft will not occur. Dental insurance is based on the likelihood that the beneficiary will use dental services. Therefore, the premiums paid for the dental insurance policy determine the amount of the benefits paid. The greater the premium, the greater the benefits, in dollar amounts and/or in number of dental services provided.
Your employer provides the plan to you as an EMPLOYEE BENEFIT. Your employer determines the amount of premium dollars he is willing or able to pay. The insurance company tailors a plan for your employer and specifies what services will be covered and what benefits will be paid to fit that premium payment.
When the plan is designed, the insurance company and your employer (sometimes in concert with your union) determine what requirements have to be met for the benefit payout. In some cases, in order for the benefits to be paid, a "pre-treatment estimate" must be filed. The insurance company will then notify you or the treating dentist what benefits they will pay. After you have received care, the claim form will be prepared by your dentist and submitted to the insurance company for reimbursement. Benefits usually do not cover the entire cost of treatment. Benefit checks, unless you have made an agreement with your dentist for assignment of benefits, will be sent directly to you. If the benefit checks are sent to the dentist, you still will be responsible for the difference between the benefits and the total fee.
Since periodontal care is usually performed over an extended period of time, claim forms may be submitted at appropriate intervals during this treatment time, when each phase of care is completed.
Disputes
Occasionally, there may be a dispute concerning what you feel is an appropriate benefit payment and what the insurance company is contracted to pay. Your dentist will provide the company with sufficient information concerning these services. The insurance company claims agent then makes a judgment in benefits of payment. If this judgment is not satisfactory to you, you have a number of resources open to you. You may issue a complaint through your company's insurance representative (in the personnel or benefits office), through your union or you may ask your dentist to request a "peer review" through the local dental society. As a last resort, you may issue a complaint to your State Department of Insurance, the agency that regulates the insurance industry.
This information about dental insurance has been provided by this dental office as a service to our patients. Dental insurance is a FRINGE BENEFIT that will help you to pay for the services you receive here. We hope this information will enable you to better understand your dental insurance program.
If you have any additional questions regarding insurance, please reach out to our to staff at 248-625-7700. We’re here for you.
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