Dental insurance is a contract between the EMPLOYER and the PATIENT. It has NO CONNECTION at all to the dentist who is providing the dental treatment. The extent of coverage varies greatly from company to company, and sometimes even within a company. It has absolutely NOTHING to do with the level of service provided by the dentist and the fee charged for these services.
An often misunderstood term used by many insurance companies is “UCR” or usual and customary. This “usual and customary” number is the maximum amount that a particular insurance company will pay for a specific procedure. It has nothing to do with the fee charged, but with the level of coverage negotiated by your employer. For this reason, estimates of a patient’s portion for any given procedure may not be exact because often there are variations in the amount that the insurance company is willing to pay based on your particular policy.
For example, if a dentist charges $100 for a filling and the coverage is listed at 80%, the patient may assume that their insurance company will pay $80 toward this filling. However, if your policy only ALLOWS $90 for a filling and your policy ALLOWS 80% coverage of this amount, then the insurance company will ACTUALLY Pay $72 toward the service, not $80. So instead of the patient paying $20 out of pocket, they will actually be paying $28 (the remainder of the dentist’s $100 fee). This is a common point of confusion, because the percentage given by the insurance company are not of the DENTIST’S FEE but are percentages of the ALLOWANCE of the insurance policy.
Summit Dental Care’s policy on dental insurance is as follows:
Our office makes every effort possible to assist you with your particular insurance coverage. Although it is not required, we will prepare and submit your insurance forms free of charge as a courtesy. We will also provide an estimate that will show expected insurance reimbursement and patient share for each procedure. Our office can only ESTIMATE what the insurance company will cover because most insurance companies will not disclose their exact ALLOWANCES. The patient’s estimated share will be due at the time of treatment. Should our estimate of the patient’s share be too high, a credit will be issued to the account or refunded to the patient if requested. Likewise, if the estimate was low, the remainder of the balance will be due at the time that the insurance payment is received. Should no insurance payment be made within 60 days of a submitted claim, the fee will become the sole responsibility of the patient who may choose to take it up with thrir insurance company at that time.