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Isn’t my dental office supposed to know my insurance benefits?


As a person who has insurance with a given insurance company, I receive an explanation of benefits within a booklet of benefits that my employer gives to me when I sign up for a plan. In that booklet it breaks down what company covers my medical insurance, my prescription insurance, my eye insurance, and my dental insurance. Often a different company is used for each type of insurance. I personally have four different companies that handle each division of my insurance. Within each insurance plan is sub-groups that further determine how much the insurance will cover for a certain type of claim.

For example, if I pay $4 per month for my dental insurance, my employer might match $4 per month and my monthly premium is then $8 per month. I might be very excited to have this plan because it seems very inexpensive. When I receive my booklet of benefits, I read that due to my low monthly premium, I have a $5,000 deductible to meet before my insurance will cover any dental related procedure. Now, I have a toothache and my plan doesn’t sound so good. Because of my low monthly premium, I have a high deductible. When I go to see the dentist I am responsible for the full cost until I reach my $5,000 deductible, at which point, the insurance will then start paying some of the cost of the work.

In another example, say I choose the dental insurance that costs $750 per month. I like this plan because it says that it covers crowns, bridges, veneers, braces, whitening, etc. I just have to go to a certain “in-network” dentist. I call my insurance company to make sure that my dentist is “in-network” to find out that he is!! Now, I have a toothache and I go to the dentist and I don’t have any out-of-pocket expenses. But, I decide that I like another dentist better and decide to go to him for another procedure… this dentist is “out-of-network” with my insurance. Now my insurance is saying they will only cover a portion of the expenses & the office is only giving me an estimate. I don’t understand why they can’t tell me the exact cost that I will owe??

When a dental offices calls insurance companies to determine how much they will cover for your procedures, they often give very vague information. The insurance will tell the office that according to your plan they will cover a yearly maximum, they will say what your deductible is if you have one, they will inform the office of how many cleaning you can have per year and at what frequency. They might say that they may cover 50% of a specific procedure. But as we determined before insurance companies have a fee schedule that determines how much they think a procedure should cost & these are never released. So, for example the insurance may say that they will cover 50% of a filling. (But according to their fee schedule a filling should be amalgam and should only cost $20-for example- so the insurance is actually willing to pay $10. When the filling is done it is actually a tooth-colored filling that cost $50- so now you owe $40). The hard part is that the office doesn’t know exactly how much the insurance will cover until the insurance is actually billed for the procedure. And it is illegal (insurance fraud) to bill for a procedure that has not been done, therefore, the office can only call and get an estimate. This is why it is very important for each person to know their individual plan.