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

For those just catching up the past couple weeks we have discussed how 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 put together this four part blog series where we have been reviewing 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 discuss what Pre-Existing Conditions are, Coordination of Benefits and Frequency Limitations.


Pre-Existing Conditions. A dental plan may not cover conditions that existed before you enrolled.  Many people come to us and are diagnosed needing dental treatment and then wish to enroll in a dental benefits plan but may times the needs they have are not covered because of this clause.  Other examples are benefits not being paid for replacing a tooth that was missing before the effective date of coverage, also known as a missing tooth clause.  This is something your dental office can help you understand.


Coordination of Benefits or Nonduplication of Benefits. These apply to patients that have two dental benefit plans when the benefit payments from all means should not add up to more than the charge total.  Even though you may have two or more dental plans, there is no guarantee that all the costs will be covered by the various plans.  Many times both will pay a portion. Sometimes none of the plans will pay at all! Each insurance company handles COB (coordination of benefits) in its own, convoluted, way.


Plan frequency limitations. This one we are constantly monitoring in office as a dental plan may limit the number of times it will pay for a certain treatment such as your cleanings, xrays and examination.  Many times patient need treatment more often then what the frequency limitation dictates and we have to make decisions on what is best for the patient’s health, not just by insurance coverage restrictions.


Next week, in our last of this four part series we will discuss what an insurance company means if they report something was “Not Dentally Necessary” as well as bundling, downgrading, and “least expensive alternative treatments.”