The ProSmiles Dentistry Blog

"I don’t want to schedule that crown today if my insurance is not going to cover 100%." Unfortunately, this is the feedback that we receive from patients all of the time. Sometimes we hear this when it comes to x-rays, exams, or treatment that the doctor is recommending. It helps me realize that we have not done a good enough job educating our patients about their dental needs and the potential outcome if they do not have treatment done. It is difficult trying to explain to people that their dental insurance companies cannot see what we see in order to determine what is needed to properly treat and diagnose a person including something as simple as x-rays. I often wonder how many things like that get missed because of the misconception that if insurance doesn’t cover it, we shouldn’t be doing it. When the truth is, insurance companies are making business decisions, while we are making health decisions. It wasn’t too long ago that having dental insurance was viewed as a great benefit…a “must have”. Over the years, there have been small changes that have had an impact on both the patient and the providers of care. Not all change is good or bad, it is just different and it is our job, as patients and providers, to work together to maximize your dental benefits while putting patient care first. While treatment is our number one priority, I have compiled a list of information, to help you navigate your insurance, based on some commonly asked questions: Q: What is the difference between and “in network provider" and "out of network provider”? A: An “in network” provider has signed an agreement with an insurance carrier, accepting fees set forth by contract. An “out of network” provider has NOT signed an agreement with the carrier. This means the patient is responsible for the difference between what the dentist charges and what the insurance company pays. It is important for you to understand that some plans will let you go out of network and some won’t. However, you will benefit most if you visit an in network provider! We strongly encourage you to check with your insurance company prior to your visit to inquire of any restrictions. Q: What are the top reasons we see insurance claims denied? A: Filing limit timed out: It is very important for you to provide your dental office with new insurance information as soon as you have it so that we can update your file and avoid delays or worse non-payment of claims. Insurance companies often set filing limits on claims. These can vary anywhere from 3 months to 24 months. Once the clock runs out on the claim, the insurance company will deny it, causing the patient to pay 100% of the service. A: Annual maximum dollars used: You should know your calendar year maximum. A calendar year is a benefit dollar amount set forth by your insurance carrier, usually per person. Once the dollar amount is met, you are responsible for any other out of pocket costs for the year, including preventive care visits. A: Not a covered service or plan benefit: You should have an understanding of your dental insurance benefits. Most dental insurance companies have websites where you can access your individual plan benefits. Most insurance websites offer helpful information such as: benefit periods, covered procedures, deductible information, calendar year maximums and frequencies. We cannot stress enough the importance of creating and maintaining a dialogue with your insurance carrier and that you should be your own best advocate. Check and make yourself aware of any waiting periods or restrictions on your plan. We do our very best to help you maximize your insurance benefits, ultimately however the relationship lies with you and your carrier but please put your treatment above all else. We are always here to help!