Why Doesn’t My Insurance Pay for This? Part IV of IV. The last piece of our four part series on insurance coverage.
The four part series continues with part II of IV.
If you are like most patients, you would love to maximize your dental benefits but are unsure of what coverage you really have. Many patients count on the dental office’s front desk to understand their insurance, quote them estimated fees, and file with their insurance on their behalf. At Katy Trail Dental we are happy to do all of this as a courtesy to you, but we would also like to educate you on some common phrases and limitations you will find in your explanation of benefits.
Alternate Benefit Clause
A very common limitation where your insurance plan will pay for the least expensive treatment, not necessarily the procedure you and your dentist agreed to perform. Many times this does mean an out-of-pocket expense for you, since your insurance will only pay a very small amount.
Most Extensive Procedure
Many times a tooth needs a couple of forms of treatment, and with this policy your insurance carrier will only pay for the most extensive procedure done on that day.
I hate this one. If their claim is denied and reported “not dentally necessary,” patients think we did something wrong or that wasn’t needed, when in actuality that procedure is excluded by your insurance company. There are many reasons a procedure can be excluded, including an age limitation, a waiting period, or a frequency issue; it does not mean that it was not a recommended treatment for you. Your dentist did nothing wrong or unnecessary.
Usual, Customary and Reasonable Fees (UCR)
I hate this one too. Each insurance company has its own fee per dental procedure code reported. You would think we would have access to them, but we don’t. We as dentists establish our fee schedules based on many things, including fees in the surrounding area, cost of materials, and chair time. An example to illustrate the scenario is: A fee for a procedure is set at $100 and your insurance carrier reimburses at $90 or less because your employer chose this plan in particular because it probably had a lower insurance premium. You will receive a statement from your insurance company saying that your dentist’s fees are above the “usual, customary and reasonable fees.” This of course would lead you to believe that your specific dentist is costly and out of your price range, when in actuality, the plan that was chosen by your employer has its limitations; your dentist is not overpriced.
At Katy Trail Dental, we know that this can be overwhelming and confusing. Call us and let us research your insurance on your behalf and help you maximize your insurance benefits.