Our Office Policy Regarding Dental Insurance

Our policy regarding your dental insurance benefits goes beyond simply submitting claims for you. We feel it is just as important to understand how to utilize your insurance choices and benefits as it is to understand the dental treatment choices we recommend for your child. We pledge to stay as up to date as possible on the ever changing world of insurance benefits, relay the general concepts to you and help you make choices which make sense for your individual family's needs. Once you've agreed to the treatment we propose and upon completion of our work, we will submit the claims to your insurance carrier. At times it is necessary to challenge the decisions of the insurance company in order to gain the benefits you deserve, and as a customer service oriented practice we will utilize our in-house insurance benefit specialists to pursue these issues on your behalf. If you have any questions at any point during the process, please do not hesitate to contact our insurance specialists.

If you have questions about your insurance policy or anything related to insurance, claims, etc. please contact our Benefit Specialist team directly at insurance@coastalkidsdental.com or by phone 843.410.0922.

Fact 1. Dental Insurance Plans are Designed Extremely Differently than Medical Insurance Plans

Dental insurance benefits differ greatly from traditional medical health-insurance benefits and can also vary quite a bit from plan to plan. Whereas medical insurance was designed to cover the majority of costs, dental insurance was designed as a supplemental aid to the individual's costs. Over the past 40 years, the premiums have certainly increased yet the benefits have not. Therefore, dental insurance is never a pay-all, but rather a great aid only.

Fact 2. Benefits are Not Determined by Our Office

Dental insurance is a contract between your employer and a dental insurance company and the benefits you receive are based on the terms of the contract that was negotiated between those two companies. At times, the benefits negotiated do not align with the dental needs of the patient. We pride ourselves in our endeavor to help you maximize your benefits, without allowing the insurance company to mandate the services provided to your child. An example of this would be the suggested provision of topical-application fluoride during your child's preventative care visit. Our doctors, the American Association of Pediatric Dentistry as well as the American Dental Association recommend topical fluoride for children 2 times per year. Most insurance companies, however, in an effort to reduce costs, only allow it 1 time per year. We would not want to cheat your child out of proper care (and an effort to reduce decay) by not providing fluoride 2 times per year just because the insurance carrier has decided to not provide that benefit to you. Instead, our policy is to inform you of the medical based importance of this recommended procedure and then allow you to make the decision which best fits your family's needs.

Fact 3. Understanding Insurance Classifications of UCR

You may have noticed that at times, your dental insurer reimburses you or the dentist a lower rate than the dentist's actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist's fee has exceeded the usual, customary, or reasonable fee (UCR) used by the company. What exactly does this mean? A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists in the area charge for a certain service. This can be very misleading and simply is not accurate. We prefer the term Insurance allowable fee structure as it is more accurate and not as misleading as the term Usual, customary, or reasonable (UCR) is. Insurance companies set their own schedules and each company uses a different set of fees that they consider allowable. These allowable fees may vary widely and have a broad basis upon which they are set by the insurance companies. In most cases, the allowable fees are set about 30% below actual industry standard so that the insurance company can make the profit they need in order to operate. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure.

Fact 4. Deductibles & Co-Payments Must be Considered

When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving the remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only at 50% then the insurance benefits will also be significantly less. MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment.

Understanding Your Dental Insurance Benefits

We receive hundreds of questions each week relating to payment, policy issues and more. Our knowledgeable staff can help you understand & maximize use of your dental insurance benefits. It's important to understand your policy, and the choices your employer may be giving you so that you can make the best decision possible to suit your dental needs. The following is a guide to the differences that exist between major groups of dental insurance policies and benefits commonly offered to employees. There are 5 groups of policies available to us all. Most dental insurance providers offer the choice of a policy matching one of the five groups. As is true with most things in life, each policy comes with a different price tag to the purchaser of the policy (usually your employer). The greater the premium, the greater the benefits to the members. The insurance carriers may refer to their policies by various names for ease of consistency we've identified them under commonly used descriptors:

Traditional Dental Insurance:

This type of policy allows you to go to any dentist in the country (You do not have to pick from a list of dentists provided in a book from the insurance company). For this policy type, as well all types of dental insurance, we submit your insurance claim for you. Most dental insurance carriers stipulate an initial deductible to be paid by the member. (Commonly $50.00). Oftentimes, the deductible is waived for preventative care (cleanings, fluoride, exams and x-rays). The deductible applies the first time the member uses his/her benefits for restorative or operative treatment (fillings, crowns, root canals, etc). This means the member would need to pay the first $50.00 of that treatment. Most policies are structured to cover a percentage of the treatment being done, expecting the member to cover the remaining percentage. Insurance companies have grouped different types of procedures into 3 commonly recognized benefit levels: Preventative care (cleanings, fluoride, exams, x-rays and sealants); Basic restorative care (fillings, simple extractions, children's pulpotomies [root canals on baby teeth], children's stainless steel crowns); and Major restorative care (adult root canals, adult crowns, bridges, complicated extractions). As an example of their percentage breakdown of benefits, they may cover preventative procedures at 100% (no cost to the member), restorative procedures at 80% of the proposed fee (leaving 20% to be covered by the member) and major procedures at 50% of the proposed fee (leaving the other 50% to be covered by the member). This is the most costly policy offered but offers the member the greatest extent of benefits.

PPO Dental Insurance:

This type of policy is similar to the traditional dental insurance in structure but adds a choice to the policy holder. The member has the choice of using a contracted, in-network provider (if there is one in the area) or using an out of network provider. The difference to the member is usually about a 10% difference in dental coverage benefits (10% less coverage when going to an out of network provider). Coastal Kids Dental & Braces, unlike most dental specialists, are in-network with many insurance companies. Feel free to contact us to discuss if your insurance policy is through one of our in-network companies. If our office is not contracted as an in-network provider, you can still be seen at our practice and utilize your dental insurance. We'll even file your dental insurance claim on your behalf.

EPO Insurance:

These plans mandate that the member use a dental provider on the list only. The goal of these policies is to provide basic dental care to the members. Because of this, these policies usually don't provide provisions for specialists as mentioned above.

These plans are commonly structured differently from a PPO plan in that the member pays a specifically identified co-pay for most individual procedures according to a fee schedule negotiated by your employer. At times, these co-pay amounts may be greater than the 20% coinsurance (for example, for restorative treatment) expected under a PPO plan. It is important to understand this because although the monthly premium may be lower (thus initially making these plans look more attractive to choose), the member may commonly pay more out of pocket upon use of the benefits. Since children in general are at greater risk of tooth decay than adults, we usually recommend to families with young children to choice up to the PPO or Traditional plan whenever possible. We have found most families with children come out financially ahead over the course of a year by doing so. In general, this is one of the least expensive types of policies to acquire so one must weigh the benefits to the cost.

Discount Plan:

This newer concept for dental coverage simply provides the member with a percentage discount across the board for all dental procedures (for example 25% off of all fees). The member is responsible for paying the remaining 75% of their dental bill. There is no deductible and no claims are filed with an insurance company. The dental office commits to providing the discounted fee. This is often a great solution for self-employed families who do not have access to group dental insurance.

Fee Schedule:

Unlike traditional insurances which pay a percentage of the dentist's fees, a plan that pays on a Fee Schedule pays a nominal, set dollar amount for each procedure code. Your insurance company will give you a copy of this schedule upon request. Oftentimes, employers allow their employees to pick the policy they wish to have, requiring the employee to pay the difference in the premiums.

Weighing your options requires important consideration. Feel free to call our office for a personal insurance consultation in order to help you pick the policy that's right for your family.