The dreaded “Why do I have to pay?”

October 28, 2015

Regardless of your practice philosophy regarding insurance management, you are bound to have heard this kind of statement from patients many times in the past.

Regardless of your practice philosophy regarding insurance management, you are bound to have heard this kind of statement from patients many times in the past.

Helping your patients understand their dental benefits and, more importantly, what they are and are not responsible for paying themselves, is a difficult task. After all, even dental professionals are often confused about what insurance carriers will and will not pay for and the seemingly endless changes that take place year after year. (Translation: insurance carriers paying less and less while asking for more and more from the dental provider.)

What is important to communicate to patients, however, is that if prescribed treatment is in their best interest, insurance coverage should be looked at as benefit and not as the reason for declining or delaying needed care.

More on insurance: Why insurance coordinators need to be flexible in today's dental world

Having a system in place to communicate insurance benefits with your patients starts with having internal credit guidelines in place that allow your treatment coordinator to present payment options based on the cost of the treatment and anticipated insurance contribution. Even if you are one of the lucky offices that does not accept insurance payments, this is valuable information to know as you will most likely be asked these questions anyway!   

Helping patients understand what "dental insurance" really means

My colleague, Diane Glasscoe-Watterson, recommends communicating with patients about their dental insurance benefits using verbiage such as, We’re happy to help you maximize your benefits, but please understand it is our experience that some dental benefit providers are making changes that may or may not be communicated to you. We promise to be fair and consistent with all our patients, but we have no control over what insurance companies ultimately do or don’t cover and at what rate.”

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Additional measures to ensure patients understand what might happen with their insurance carriers are to make sure patients know:

  • What the anticipated insurance payment will be

  • What their payment will be

  • Their insurance may not pay it all even if it states the procedure is covered 100 percent

  • There may be a remaining balance, which will be the patient’s responsibility

  • The anticipated patient portion will be collected on the day of service or prior to scheduling the appointment. (Remember, patients are less apt to cancel an appointment if they are financially invested.) 

Video: How to save time on dental insurance verifications

Review the following common questions and answers in your next staff meeting. If your team is armed and comfortable with these answers, the stress level for all will be greatly reduced.

Why doesn’t my insurance cover all the costs for my dental treatment?

Dental insurance isn’t really "insurance" at all. It is actually a benefit typically provided by an employer to help employees pay for routine dental treatment. The employer usually chooses a plan based on the amount of the benefit and how much the premium costs. Most benefit plans only cover between $1,000 (an "average plan) and $2,000-$2,500 (an "excellent" plan) of dental costs per person per year.

Related reading: 5 facts you should know about dental insurance coverage

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My plan says my exams and certain other procedures are covered 100 percent. Are they?

That 100 percent is usually what the insurance carrier allows as payment toward the procedure and not what your dentist, or any other dentist in your area, may actually charge. For example, let’s say your dentist charges $90 for an examination. Your carrier, however, may only allow $60 as the 100 percent payment for that examination, leaving you with a balance of $30 to pay.

If my plan doesn’t really cover procedures at 100 percent, why does it say it will?

Benefit plans are often difficult to understand. If any part of your plan is not clear to you, or if you are unsure as to what your plan actually does and does not cover, contact your employee benefits coordinator or the human resource department where you work for more information. This could end up saving you a lot of unpleasant surprises down the road.

Related reading: Why are some insurance companies excluding dental care? 

How does my insurance carrier come up with its allowed payments?

Many carriers refer to their allowed payments as UCR, which stands for usual, customary and reasonable. UCR is a listing of payments for all covered procedures negotiated by your employer and the insurance company. This listing is related to the cost of the premiums and where you live. UCR in New York City will likely be very different than UCR in North Platte, Neb. Your employer has been given the chance to select an allowed, or UCR, payment that corresponds to the premium cost they are looking for. Think of your plan’s UCR as a negotiation between the insurance company and your employer.  

Because the payments are negotiated, does this mean that there will always be a balance left over for me to pay?

Yes, typically there is a portion that is not covered by your benefit plan.

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If I always have a balance to pay, why have insurance at all?

Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something and reduces what you have to pay. Even if it’s not a lot, everything helps!

I received an explanation of benefits from my insurance carrier that says my dental bill exceeded the UCR. Does this mean my dentist is charging more than they should?

Remember that what insurance carriers call usual and customary is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment. It is usually always less, sometimes even much less, than what any dentist in your area might actually charge for a dental procedure. It does not mean your dentist is charging too much.

More on dental insurance: New bill before Congress targets dental insurance plans

Why is there an annual maximum on my benefits?

Maximums limit what a carrier has to pay out each year. Despite the fact that dental tends to rise a little each year, annual maximum levels for dental care have not changed since the 1960s.

Why do some benefit plans require me to select a dentist from a list?

That list will include dentists who have agreed to a contract with the benefit plan. These contracts have restrictions and requirements. If you choose a dentist on the list, you typically will pay less toward your dental care than if you choose a dentist not on the list. Not seeing your dentist on the list does NOT mean there is something "wrong" with the dentist or the office. It simply means your dentist has not chosen to participate in that particular plan.

Why does my benefit plan only pay toward the least expensive alternative treatment?

To save money, many dental plans allow only for the least expensive method of treatment. For example, your dentist may recommend an implant with your insurance only offering a benefit towards a crown. This does not mean you have to accept the crown. The good news is that some benefit (money) will be paid; the bad news is that more of the fee will be your responsibility. Remember, it is your dentist’s responsibility to prescribe what is best for you while the insurance carrier’s responsibility is to control payments.

Related reading: The top five things you need to know about dental fees

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Why won’t my insurance pay anything toward some procedures?

Your plan contract specifies how many of certain types of procedures it will pay for, or partially pay for, during a one-year period. For instance, it limits the number of X-rays, cleanings and gum treatments it will cover because these are the types of treatments that many people need more than once or twice a year.

My insurance plan doesn’t go into effect until next month. Can my dentist do my treatment today but send in the claim next month so the insurance will pay?

Nope. State and federal laws regulate these issues, and it is considered insurance fraud to change the dates of service on a claim. Both the patient and the dentist can be prosecuted.

More on insurance: How to streamline the insurance aging report

What should I do if my insurance doesn’t pay for treatment I think should be covered?

Because your insurance coverage is between you, your employer and the insurance carrier, your dentist does not have the power to make your plan pay for something you, or the dentist, thinks should be covered. It is important to remember that you are responsible for the total cost of treatment if your insurance does not pay. Sometimes a plan may pay if patients send in claims for themselves. Patients, as consumers, may also lodge complaints the state insurance commission.

Where can my employer find out what typical UCRs are for our area?

Check Dental Products Report for fee analyses for your region, and use this as a guideline when negotiating with insurance carriers.

If you would like help with handling the "dreaded" insurance question, please contact me today. We can talk on the phone (with my Coffee Break Consulting services) or plan a day to work with you and your team.

Related reading: The myth that patients should know their benefits