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Dental Insurance
More and more patients are getting help paying for their dental care through dental insurance. Dental insurance is a contract between your employer and an insurance company. It is not written by your family dentist ! You, the patient , is responsible to the dental office for any fees not paid by your insurance. Regardless of the plan, there are usually three parties involved: the patient, the dentist, and a third party with whom you or your employer contracts for coverage. If your options include a plan funded by your employer, you may have an administrator responsible for processing and payment of your claims. Read your benefits booklet carefully. Know and understand your options. Be familiar with limitations and exclusions set by the contract.
Remember, you and your dentist need to decide the treatment that is best for you no matter what insurance covers. It isn't wise to let coverage dictate treatment. Communicate with your dentist, employer and insurance company.
What is UCR? [Usual Customary Routine]
The answer to that is different from one company to another. It is often described as a fee that an individual dentist most frequently charges for a given service -- his "usual" fee. But that is not entirely all. Some insurance companies define this as the lowest fee routinely charged. Sometimes it is a fee set by the insurance company based on what has been charged in a selected area as "customary." The insurance company defines the areas and how often to update the information. As a result these fees may vary greatly. Some administrators take all fees charged in an area and then decide on a percentile for coverage. This is sometimes termed an average fee when it really is not. This may be above the actual average or below it.
What is a PPO?
Preferred provider organizations are groups of dentists contracting with an insurance company to provide care for reduced fees. Insurance companies generally do not evaluate the quality of care or dentist qualifications to become "preferred."
Capitation:
Some dental offices receive payments whether or not enrolled/assigned patients come into the office. Often, patients are required to pay surcharges for certain procedures. This type of plan is termed "capitation." It is to the dentist's benefit not to provide his best care for you under these plans as he gets paid a set amount for each patient regardless of the quality of care he provides. So, as an example, patients may receive fillings when a crown is the best treatment choice. The dentist earns the most if a patient does not come for a visit.
Table of Allowances
Your employer may purchase a contract that sets specific dollar limits for each covered procedure. These limits may not cover the total cost of treatment. You are responsible for the difference. Such a plan is under a "table of allowances."
Co-Payment
A co-payment is that part of the dental fee not covered by insurance. It is unethical and in some cases illegal for the dentist to forgive the co-payment.
Pre-Authorization
Some contracts require you to send in treatment plans before your treatment starts. The insurance company then tells you what benefits will be paid. Caution: changes in treatment plans may require notifying the insurance again to check your coverage. Some companies set expiration dates on these predeterminations.
Adequate or Alternate Treatment
There are plans where the employer contract allows the insurance company to pay for a less costly treatment. The insurance company may call this treatment "adequate or an alternate." For example, a partial denture may be a covered expense while two fixed bridges are not covered. Both replace missing teeth, but the bridges are more costly and therefore not covered. Fixed bridges are far superior restorations, however.
The bottom line is not to allow coverages to dictate your treatment. If you are informed, you will be able to make a decision that will make you comfortable and happy.
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