Insurance - Kids Pediatric Dentistry
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Our Office Policy Regarding Dental Insurance

It is our goal to help you receive the maximum benefits available under your dental insurance policy.  We are an out-of- network provider with all plans. As a courtesy to you, we will file your claims with your primary insurance company, but need your cooperation. We request you read and understand your dental plan benefits prior to seeking treatment.  It is important to provide the office with the necessary information to verify your benefits.  All insurance information should be received at least 24 hours prior to the dental appointment. If not received, you will be responsible for payment of all fees upfront and the insurance company will send reimbursement to you.   The day of the appointment is reserved for clinical matters.  All business matters should be handled prior to the day of the appointment.  MOST IMPORTANTLY, please keep us informed of any insurance changes:  change of employment, insurance carrier, insurance company address, policy name or identification numbers.

Your insurance benefits are a contract between you and your employer. The amount of coverage you will receive will depend on the quality of the plan purchased by your employer, not the fees of the doctor. Your deductible and the estimated portion not covered by insurance is always due at the time service.   A new bill, Texas Senate Bill 554, was passed into effect on September 1,2011 states any procedures not covered by the dental insurance can be collected at the dentist’s usual and customary fee instead of the insurance’s contracted amount.

Fact 1 - No insurance pays 100% for all procedures

Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage, or the type of contract your employer has set up with the insurance company..

Fact 2 – Benefits are not determined by our office

You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, insurance companies state the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (“UCR”) or “Allowable” used by the company.

A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable, or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate.

Insurance companies set their own “Schedules” and “Allowable”, and each insurance uses a different set of fees they consider allowable. These allowable fees may vary widely, because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “Allowable” Fee. Frequently, this data can be three to five years old and these “Allowable” fees are set by the insurance company so they can make a net 20%-30% profit.

Unfortunately, insurance companies imply that your dentist is “overcharging”, rather than say that they are “underpaying”, or that their benefit levels are low. In general, the less expensive insurance policy will use a lower “Allowable” figure.

Fact 3 – Deductibles and Co-Payments must be considered

When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming your insurance company allows $150.00 as its allowable fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% of the remaining balance for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Therefore, your portion of the bill is $70.00. Of course, if the allowable is less than $150.00 or your plan only pays  at 50%, then the insurance benefits will also be significantly less.