WHAT EVERYONE SHOULD KNOW ABOUT DENTAL INSURANCE
Participating Insurances: We participate with Cigna, United Concordia, Delta Dental, Metlife, Guardian, NYS Teamsters , United Health Care PPO and United Health Care Community (Child Health Plus, Family Health Plus and Medicaid) insurances. Essentially, what this means for you is that we have an agreement with each of these companies which determines the maximum amount of patient's financial responsiblity for covered services. This does not mean that you receive "free" treatment! It does however, make it much easier and more predictable for us to calculate what your personal "out of pocket" responsibility will be. Since we have an agreement with your insurance company they will send the payments directly to us.
Assignment of Benefits: We may not "participate" or have a specific agreement with your insurance company but in most cases, we will accept the assignment of benefits. Basically, this means that we will only require you to pay the amount that insurance is not expected to cover at the time of your appointment. We will still submit your claim but we will wait up to 30 days for them to send us the payment. In most cases the insurance company remits the expected payment with in 30 days and you are all set until your next visit. If for any reason your insurance company fails to pay the expected amount or fails to process the payment with in the 30 days; you will be directly billed for the balance due.
Non-Assignment of Benefits: There are a couple of insurances which we will not accept payment from and in those cases, though we may still submit claims on your behalf; you will be responsible for payment in full at the time services are rendered and the insurance payment will be sent directly to you. Blue Cross/Blue Shield, GHI, and GEHA are a few examples. If you have coverage through one of these companies you are still welcome; but you will be responsible for payment in full for all services.
Claim Submission: If you are fortunate enough to have dental insurance and you have provided us with all of the necessary information at the time of your appointment; we will be happy to submit your claim for you. You must be familiar with your insurance coverage as we will be collecting from you the estimated amount insurance is not expected to pay. Payment for professional services is due when treatment is provided.
By law your insurance company is required to pay each claim with in 30 days of receipt. We file most claims electronically ensuring that your insurance company receives them with in a couple of days of your visit. We are not responsible for how your insurance company handles its claims or for what benefits they pay or don't pay. We can only assist you in estimating your portion of the cost of treatment. We can NEVER guarantee what your insurance will or will not do with each claim nor can we be responsible for any errors in filing your insurance. Once again, we submit claims as a courtesy to you.
Benefit Determination: Benefits are not determinded 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 that the reimbursement was reduced because your dentist's fee has exceeded the usual, customary, or reasonable fee "UCF" used by the insurance 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 is simply not accurate.
Insurance companies set their own schedules, and each company uses a different set of fees which 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 "allowable" to set their "UCF"~(ususal and customary fees). Frequently, this data can be three to five years old and these "allowable" fees are set by the insurance companies so they can make net 20%-30% profits. Unfortunately, insurance companies imply that your dentist is "overcharging", rather than say that they are "underpaying", or that their benefits are low.
Coverage: No insurance pays 100% of all procedures. Many patients think that their insurance pays 90%-100% of all dental fees. This is simply not true! Most plans only pay between 50%-80% of the average total fee and some have a set "schedule of allowances". 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. Dental insurance is meant to provide some assistance; it is intended to function as a supplement for the cost of receiving dental care.
Deductibles/Maximums/Limitations: Insurance companies can have many different plans. For example: let's say you have a guardian plan and so does your neighbor who works at the very same company. Your brother also has guardian insurance yet he works for a totally different company. Just because all three of you have guardian insurance doesn't mean that you have the same plan or coverage...not necessarily even the two who work for the same company! This is why it is imperative that you familiarize yourself with your own plan. You need to know your benefits.
Insurance plans may also have different rules, regulations, limitations, waiting periods, deductibles and policy period maximums. This makes it impossible for us to keep track of everyone's coverage. So, although we understand that dealing with insurance companies is challenging, and we will do our best to assist you; ultimately you are responsible for for knowing your own coverage.
***Please keep us informed of any insurance changes such as policy name,insurance company address, or any change of employment status.***