So you’ve received a dental billing statement, and you’re wondering why the amount is more than what was estimated. Many times the patient will think it is a billing error, when actually it is how their particular dental insurance plan is structured. And for most individuals, understanding their insurance plan can be frustrating, especially when you receive a bill from your dentist.
1) Composite Fillings
-tooth colored filling material used to fill cavities or replace old fillings
Many PPO’s will substitute the cost of a silver amalgam filling when a composite filling is completed. e.g. 2 surface composite filling costs $160. Your insurance will pay 50% for fillings. Patient pays $80 at time of service. The remaining $80 is billed to dental insurance. Dental insurance processes the claim and substitutes a silver amalgam filling which is $120 and pays 50% of that fee which comes to $60. The patient will receive an EOB (Explanation of Benefits) saying that an alternate benefit was applied, and the patient will be billed $20 to cover the remaining balance of the $160 composite filling.
Frequency Limitation-this clause will only allow a tooth to be filled only once every 3 years or whatever limit the dental insurance sets for your plan. e.g. so if you have a filling placed on a molar, and 1 year later the filling broke while eating popcorn, your insurance will not provide any benefits for the replacement filling on the same tooth. If you have a cavity on the same tooth, but the cavity on a different surface of the tooth, then your insurance will provide benefits for the new filling on the new surface of the tooth.
2) Porcelain Crowns–for severely cracked, broken, and extensively decayed teeth. How insurance handles porcelain crowns and crown buildups can also be frustrating.
For example, a porcelain crown for a molar has an insurance fee of $840. The crown buildup has an insurance fee of $120. Insurance plan says 50% of major work is covered. So out of the total $960.00 that the patient is responsible for, we would expect $480 to be covered, right? Well, here are a few loopholes insurance companies can use that you will need to be aware of. An alternate benefit of an all-metal-crown(no porcelain) can be used on posterior teeth (premolars, molars). The cost difference between an all-metal-crown and porcelain crown will be the patient’s responsiblity.
Crown /Core Buildup–most dental insurance companies will pay for this part of the crown procedure. However, many are not including part of the benefit leaving the patient with a balance in the end. Some insurances will only pay for a crown buildup only if a root canal was completed on the tooth. Attrition or severe wear is not enough to qualify for a crown with many insurance companies. Even if you have worn through the enamel and your teeth are sensitive.
Frequency limitation–most insurance companies will usually help pay for a crown to be replaced every 5 years. Some will pay for a replacement every 10 years.
3) Many times the deductible will be added to the cost of the service by your insurance. The deductible is the amount the patient is responsible for based on the type of insurance plan the patient signs up for. Some deductibles are $25, $50, $100.
So is it possible to anticipate all these ridiculous loopholes insurance companies can use? First, if you get a treatment plan from your dentist
, call your insurance company and ask a representative the following questions:
- Are these services a covered benefit? If so, how much is covered? Read out the procedure codes line by line. The procedure code is a 4 digit number that precedes the service description.
- Will an alternate benefit be applied to this procedure code?
- Will your deductible be applied to this particular dental service?
- Do you have remaining benefits left in the year?
- Is there a waiting period before you can start any dental work?
4) Can the dental front office staff verify this information for the patient?
The dental front office is a very busy place, and many times when we call the insurance company (after being on hold for a very long time), we will get a representative who will only give us a basic breakdown of benefits. Many times the representatives will not give us details because we are not the patient. Some of the loopholes may not be disclosed to us and many times the representative will inform us that benefits are never guaranteed. So we do ask our patients to call their dental insurance or call our office if they have questions regarding their statement.