Frequently Asked Questions

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.

We see many patients who are presented treatment plans that they cannot afford.  We will help find a way to prioritize your treatment. Many of our patients have their dental work completed in our office for reduced fees.  If you have a treatment plan, feel free to call or email us about discounts and ways we can help you make your dental treatment financially more flexible. Complimentary consultation is always available and never feel pressured to have your dental work started.
What is PPO insurance and how does that differ from HMO/DMO?

PPO insurance (Preferred Provider Organization)– will have the largest network of dental providers and specialists. You have the choice to see any dentist and specialist. Deductibles and co-payments must be made in addition to monthly premiums.  Not all dental procedures are covered with certain PPO’s and there will be frequency limitations on certain services. There can be delays in payment of claims, and some insurances have waiting periods before qualifying for dental work after enrollment.

HMO/DMO (Dental Health Maintenance Organization)–is less expensive, but limits who the patient can see as a provider. Usually there are very few dentists who will participate with DMO, and you will likely be assigned to the dentist in your area. The fee schedule is discounted much more than PPO’s. Very few dentists and specialists will participate with DMO’s because they do not feel comfortable seeing a high volume of patient’s in a day to make up for the very low fees. We currently do not participate in DMO/HMO plans.

Dental Plan/Discount Plans–typically requires an annual membership fee. No co-pays or deductibles need to be paid. No paperwork or filing of claims need to be completed. The fee schedule for such a plan is discounted 20%-70%. However, not all procedures are discounted and the number of dental procedures discounted are very few. Lab Fees, Office Visit Fees, Sterilization Fees, are common with discount plans.

Many of our patients ask what plan or dental insurance can save them the most money.  First, you need to assess what your needs are.  Many Dental PPO’s will have an annual limit of $1000-$2000 a year.  If you have relatively healthy teeth with little or no major dental restorations, then paying monthly premiums for dental insurance makes little sense.