Many people mistakenly believe when they go to their dentist who is contracted (or in network) with an insurance company, (say Delta Dental), the dentist represents the insurance company. Not True. Your dentist receives a fee schedule, the insurance company’s fee schedule, at the time they contract. This gives the dentist a right to be advertised on the insurance company’s list of in network providers. Being “In Network” dictates the maximum fee the dentist may charge for treatment procedures allowed by the insurance company. (For example: The regular fee for a crown is $1000 but the insurance contracted fee is $800.00 and they pay 50% of that. The dentist then cannot charge more than the contracted fee for allowed procedures.)
Your dentist has NO relationship beyond this agreement with your insurance company! And remember (technically), no dentist is obligated to determine benefit allowances, bill your insurance, or deal with the problems that may come up to collect from the insurance company…In network or not! Except for the fact they want to get paid for services provided. Dealing with insurance is very time consuming and expensive for a dental clinic. It requires hiring full time insurance billing staff to ensure navigating through the complications and requirements involved with filing claims to collect from the insurance companies.
Insurance billing service has kind of evolved into a “required service” due to the language, code submission complications and other details the patient is not in a position to understand or deal with in many cases. For these reasons, insurance billing services are not optional for a majority of clinics. Clinics simply must offer this service unless they only do business on a cash basis, not too realistic in today’s world. But it is a service provided that is often misunderstood and little appreciated by patients.
So you have insurance, and you go to the dentist; here is generally how it will work:
- Your dentist office will call your insurance at the time of service, or before, to verify eligibility, and for “ESTIMATED” benefit allowances for different procedures under your plan. I emphasize “estimated” as ALL insurance companies include a disclaimer by phone or online which state that all benefit percentages provided are “not a guarantee” and are only “estimates of coverage payment”. (I’ll get to why shortly.)
- Your dentist will present to you, hopefully in advance of treatment, what the total fee is for the procedure you need, and what “estimated” percent your benefit plan pays of that procedure. The balance remaining is the Co-Pay or out of pocket expense to you. Most plans also require a deductible charge that must be collected at the time of service.
- Your dentist performs the procedure, you pay your deductible and co-pay, the clinic bills the insurance company for the benefit allowance, and everyone is happy right?
Not so fast. The devil is in the details as they say. Here are just a few details that often put the dental clinic in an undesirable position. These details are why dealing with insurance companies can be: expensive, patient relationship damaging, and generally a pain in the back side for dentists. So let’s talk “Codes”, “Estimates”, and “Billing”.
Your dentist determines “Clinic fees” he or she will charge for various treatment procedures (known in the profession as “Usual and Customary Fees”), according to a list of fees that are usual and customary for your area, according to the zip code of the clinic location. These fees are recommendations that range from a low end fee, mid range fee, or high end fee for a particular procedure. The particular fee your dentist may select depends on lots of factors, generally related to the overall cost of business. All dental treatment procedures are assigned a “code number” that all dentists use. These codes are universal and every dentist must use them to define the treatment procedure and corresponding charge for billing.
Insurance companies use these same codes in billing. However, they establish what dollar amount or percent will be assigned a particular procedure code for an individual plan benefit. They also limit the Maximum fee (as mentioned above) the dentist may charge for codes/procedures covered by an individual plan. Not all codes or procedures are automatically covered. Insurance company benefits under your plan (what codes are covered and what percent of the fee is covered) vary according to the plan benefits established by your particular plan.
What codes are covered can often have “conditions” attached to them that allow for denial of payment for all or part of what you (and the dentist) think is covered, based on what information is provided at the time they call for eligibility and benefits for your plan.
For example: Joe patient goes to a great Emergency Dental Care clinic that provides same day care on a Saturday because his tooth is throbbing and nothing helps. His regular dentist is closed until Monday. The emergency clinic dentist also is in network with his dental insurance carrier, so Joe is not concerned. Joe decides to get the work done, makes his co-pay, and does the treatment. A few months later, Joe gets a bill from the clinic for the full cost of the exam and x-ray! Why?
Turns out under his individual plan, there is an exclusion or condition for “Emergency Care” which says the treatment procedure cannot be performed on the same day the Exam and X-ray is done! Benefit denied. Joe did not know this, and when the dentist’s staff called in to determine eligibility and benefits, they can’t learn of these disqualifying conditions either. It’s extremely frustrating for patients and the dental clinic alike.
As another example, the dentist does not know the patient he just helped used up the plan annual allowance for “preventive “care exam and x-rays, two days before at another clinic. This fact was not available at the time of billing and payment ends up denied. So the dentist ends up sending out bills and often is left unable to collect for service provided.
These are just two examples of many that could be given, of issues that come up dealing with insurance for patients. That is why most dentists, when presenting the cost for treatment to patients using insurance, make sure they sign for the fact they are ultimately responsible for the total amount of service fees. Eligibility and Benefit allowances are all the dentist can determine up front! The fine print exclusions, only the insurance company is privy to, are the reason dentists and the patient only get “Estimates” of coverage at the time of service.
Here is another common insurance problem. Let’s say a patient has a refund coming for fees charged by the clinic at the time of service (because the clinic is not sure the insurance will fully cover a portion of the treatment). A week, a month goes by and no refund has arrived from the dental clinic. The patient calls the dentist’s insurance clerk and is told no check has been received from the insurance yet! Upset, they call their insurance company who tells them, yes! that check was processed and was issued to the provider. So they call back the dental clinic convinced someone is lying and earning interest off money received but not refunded.
It’s not that the insurance company representative lied, or that the dental clinic did, its often what the insurance company representative does not tell the customer that is the problem. (You see they don’t want to be the bad guys, it’s just prudent for them to let the dentist take the heat.) The claim may have been received, a check issued, and they may even provide a date when it was done! But all of those true facts may not mean the check was actually approved and mailed! Standard procedure may be to approve issuing a check, but the next standard procedure may be to have the claim reviewed by in-house dental review experts to determine if the claim is clinically legitimate. Or, they may request additional information or x-rays from the clinic, before the payment is actually approved to send out. Whatever; sometimes receiving payment just takes forever and you (and the clinic) can never figure out why? If you have been around very long you have learned insurance carriers for anything expect prompt premium payment, but often exercise the right to delay benefit payments until every (t) is crossed and every (i) dotted of their own making.
When something like this happens to a patient, and they are under the misguided belief the dentist is in cahoots with the insurance company, or is being dishonest, who do you think they call first to vent their anger? Most often the dental clinic!
Yes, just like in all industries there are more trustworthy players than others. That’s true for insurance carriers and dentistry as well. If you have dental insurance it is a blessing to help you afford dental care. Most dental offices want to help you get the maximum benefit allowed under your plan.
Hopefully this article gives the reader a tiny glimpse into the complications in dentistry of managing claims for a host of individual plans through multiple insurance providers. But I trust folks at least take away an understanding that dentists are NOT partners with or in collusion with, Insurance Companies.
So who should you trust? That’s for you to use your best judgment about. But remember, unlike the people making decisions about claims and cutting checks for some huge far away insurance company, your dental care provider is local and accessible to meet in person. Should you become dissatisfied or encounter a problem along the way, remember the dental office person who is handling insurance claims for you, usually has no reason not to help you understand and resolve insurance issues (unless you give them one). They are usually more than willing to work with you, as the dentist can’t get paid either unless insurance payment issues are resolved.