If you have dental benefits, do you know what your plan covers? Is it the right one for you? Dental insurance can be confusing, but we’re here to help!

Most policies cover preventative / basic work such as exams, cleanings, fillings, root canals and some surgery (extractions). They might also cover major treatment such as crowns, bridges, implants, dentures and orthodontics (braces or Invisalign).  Preventive / basic work usually has the highest percentage of coverage (often 80-100%), and major treatment is usually covered at approx 50-60% of the fee guide that your insurance subscribes to. Most plans have annual maximums as well.

For preventative treatment, most policies cover your x-rays and exam once a year, and a specified amount of time for cleanings per 12 month period. We base your cleanings on your specific dental hygiene needs, not based on your insurance plan, but will keep you informed of your options.

Since insurance plan policy information is very private, we as a third party sometimes receive limited information.

A dental plan may elect not to cover some procedures at all. It’s advisable to go over your plan before starting any new dental procedure, to ensure you avoid any billing surprises. For major treatment plans, we can also try to maximize your insurance by planning treatment over two benefit years.

Dual Insurance

Insurance plans will coordinate — which means if you are covered under two plans, they will both pay toward services provided. Sometimes this means you will not have any balance owing. Depending on the way your two plans coordinate, or the procedure you are having done, there still may be a portion to be paid out of pocket. In some cases, a signed form will have to be submitted for the second insurance.

Dental Insurance vs Health Spending Account

Often patients have a health spending account (HSA) in conjunction with their regular dental insurance. In this case, the amounts not covered by your dental insurance may be reimbursed to you directly through this account. Some patients have this benefit available to them, but are unaware. If you are uncertain about what your HSA covers, be sure to ask your HR department!

Fee Guides

Just as dental offices have different fee guides, insurance companies also follow their own set fee guide. It’s important to note that dental office fee guides dictate what the procedure should cost. Insurance fee guides dictate how much of the cost they’re willing to cover. Unfortunately, these numbers don’t always match, resulting in a balance owing by the patient.

An example of this:  If a procedure cost $100 at the dental office, and the insurance plan covered 100% of $80, they would cover $80 of the procedure, and you would be responsible for the remaining $20.

Balances owing can get tricky to estimate on your own, if multiple procedures are planned, or more extensive treatment is involved. That’s why we’re happy to send a pre-determination for you, and review pre-approved treatment expenses prior to getting started! Taking this approach will accurately estimate how much your plan covers and your out of pocket expense for treatment.

Predetermination Estimates

For major treatment especially, our wonderful front desk team can submit a predetermination on your behalf. This may involve photos of your teeth, x-rays, or other documents. Your insurer will then contact you directly to let you know if they will cover some (or all) of your treatment. Due to privacy policies, the dental office rarely receives a direct response. This information is always sent to the patient, either by regular or electronic mail. This will help you better anticipate your patient portion. Again, we’re happy to review these documents with you, upon your receipt of them.

Timing

In most cases, claims are processed in 2-5 business days. Pre-determinations can take approximately 2-3 weeks to be processed by insurance.

Direct Billing

We’re pleased to offer direct billing at our practice, limiting financial strain on our patients.

In most cases we know what your insurance is paying, and therefore, your patient portion before you leave our office. If for some reason we do not get confirmation of the insurance payment, we ask that you either provide a credit card on file for future processing, or pay the full claim amount, and we will have your insurance provider reimburse you directly.

At Tooth Works, we’re here to help you achieve your smile goals. We understand that finances play a role in your decision to pursue dental treatment, and we’re ready to help you every step of the way — from predetermination, to direct billing, to financing if needed (see our policies for more details). If you have questions that weren’t answered in this blog post, please ask at your next appointment, send us an email (info@toothworksonline.com), or give us a call (780-428-7830).

Yours in better dental health,

Tooth Works