How Does Dental Insurance Work?
First we determine whether we participate with your insurance plan(s).
If we do not, we are considered Out-Of-Network, and your treatments will be charged according to our office’s fee schedule. Payment will be taken prior to any procedures being performed.
If we do participate, we are considered In-Network, and your treatments will be charged according to the contracted rates that our office has agreed to with your insurance carrier. This contracted (negotiated) fee is the absolute maximum our office can bill for. This amount is a shared responsibility between you and your insurance company, they pay a certain % and you also pay a certain % of the negotiated amount. The amount or percentage of coverage you have varies from treatment to treatment and is set forth by the plan that you and your employer selected. Amount of coverage is never set by your dentist, that’s determined by your group-number.
Now, in the ideal world, your insurance company will pay their percentage of these negotiated amounts as described in your benefits. However, insurance companies are quite savvy with loopholes and technicalities that allow them to stall or even withhold their fair share of the fees. Unfortunately, in these instances, it is the responsibility of you, the subscriber, to now cover the insurance’s share. Now, we will do everything in our power along with the help of our expert team of insurance coordinators to get the insurance companies to pay what they should, but it is not always possible, and there are legitimate limits to their payouts. We are on your team!
But as a small business, we depend on timely and complete payment in order to continue serving our valued clients, such as yourself. So, what we will do is collect the percentage you are expected to pay for after the claim is settled (co-insurance), and wait for the insurance to pay the remaining balance you should be entitled to. However, if the insurance company denies coverage or pays less than is estimated/expected, it is still the patient’s responsibility to make up for their lack and satisfy payment of the full contracted amount. We will help as much as we can; we will re-submit claims, provide them with additional information, and provide them with narratives explaining the necessity of treatment if requested. However, if after 60 days, the insurance company has not paid for the remaining balance on your account, you the patient or account holder will be responsible for paying the remaining balance. We will charge your card on file for the difference, but not to worry though, we will remain providing any help or information you need to receive payment from your insurance companies.