Why Doesn’t My Insurance Pay for This? Part II

Last week we touched upon how having a dental insurance plan can make getting the dental care you need easier but does not always cover all the costs associated with prevention and treatment in the dental office.  We have a four part blog series where we will review some of the cost-control measures that are taken by your dental benefits plan to keep costs low on their end but as a result, push fees back on to you as the patient.  This week we define UCR, Annual Maximums and treatment by different kinds of Providers.


UCR stands for Usual, Customary, and Reasonable.  UCR charges are the maximum allowable amounts that will be covered on a plan.  Although this sounds as if the UCR fee is the standard or going rate for dental care is it not.  This is very misleading as insurance companies can set whatever amount they want for UCR fees and they are not set by demographic or the current and actual fees charges by most dentist.  If may not even be from the state you are in!  The company’s UCR fees may stay the same for years and the fees in dentistry have not.  Additionally and absurdly enough, insurance companies are not requires to disclose how the set their UCR fees and each one has their own formula.  Frustrating, we know!


This being said, if your dental bill is higher than your UCR fee this DOES NOT MEAN YOUR DENTIST CHARGED TOO MUCH.  If more likely means that your insurance company has not updated their UCR fees which is unfortunate for the plan participants.


Annual maximums are the largest dollar amount your dental plan will pay during one given year.  Your employer decides the maximum levels of payment in its contract with the insurance company.  Copayments are the responsibility of the insurance as well as any costs above the annual maximum.  This is far more common than you’d imagine.  Annual maximums are not always updated to keep up with the costs of dental care and if the max of your plan is too low you can ask your employer to look into plans with a higher annual max.


Lastly, preferred providers.  Your plan will want you to choose their preferred providers as these dentists have a contract with the insurance company, these are not necessarily the provider the patient prefers.  On most insurance plans you are free to choose whichever provider you would like and you are free to seek dental care from a dentist that is not in-network.  Many plans have the same coverage in and out of network.  Many times the level of service of the out of network provider will be higher as they are not contracted by the insurance company to plan by their games!  This is something we can help you with and explain better in office or over the phone.


Next week we will discuss what Pre-Existing Conditions are, Coordination of Benefits and Frequency Limitations.