Demystifying Insurance: Part 2

Demystifying Insurance: A Two-Part Guide

Part Two: A Full Understanding

Insurance is perplexing, but the dentists and staff at East Portland Dentistry are committed tomaking sure that patients understand the benefits and the limitations of their policies. Dental insurance does not cover all procedures and may not cover the entire cost of dental treatment. As most dental plans are contracted through patients’ employers, employers dictate the allotted coverage by how much they contribute. We value our patients’ oral health and urge patients to discuss coverage dissatisfaction with their employers.

To help eliminate the confusion that may arise when patients receive insurance statements and dental bills, we offer the following clarification. First, it’s important to make sense of some misleading terminology. Insurance companies refer to the maximum allowable amounts covered as UCR, which stands for usual, customary, and reasonable charges. While such phrasing suggests that there is a standard rate for dental treatment, no such standard exists. Insurance companies determine their own UCR rates according to their own formulas and are not required to disclose how they establish their rates. At East Portland Dentistry, we are happy to price our services prior to treatment so that patients can discuss their potential out-of-pocket costs with their insurance companies.

Dental plans also carry an annual maximum, which is the largest sum that insurance will pay per year. When dental needs exceed the annual maximum, patients are responsible for additional costs. Moreover, some dental plans put a cap on the number of times allowed for certain treatments, such as teeth cleaning. This is referred to as plan frequency limitations. At East Portland Dentistry, our primary concern is our patients’ oral health; thus, we may recommend treatment that exceeds insurance benefits if we deem such treatment dentally necessary. While insurance companies employ cost-control measures to ensure their profits, our dentists do not cut corners, as oral health is our objective.

Please also be aware that many insurance plans designate preferred providers, meaning that the insurance companies have contracts with certain dentists who are referred to as “in-network” providers. A “preferred provider” is not a term for a dentist who is more qualified than another; rather, the phrasing simply pertains to dentists who have contractual agreements with a particular insurance company. If East Portland Dentistry is not listed as a preferred provider with your plan, out-of-pocket costs may be higher. Please inquire when scheduling if you are concerned about whether our dentists contract with your insurance plan. We prefer to avoid unhappy surprises so that our patients keep smiling!

A further concern with limitations of dental coverage is pre-existing conditions. Dental plans may not cover conditions that existed prior to enrollment in the plan, or the plan may enforce a waiting period before coverage applies. Another dental plan limitation occurs when insurance regards a procedure as not dentally necessary. Please be aware that you can appeal if your insurance rejects a claim as dentally unnecessary. Ultimately, our dentists may recommend treatment of a pre-existing condition if we consider it medically necessary. Additionally, we may propose procedures that your plan regards as not dentally necessary. We will discuss the benefits of a healthy mouth versus the impact of postponing or neglecting treatment that is not covered by

There are a few more dental plan limitations of which to be aware. Coordination of benefits (COB) applies to patients covered by more than one plan. Sometimes, even though patients have multiple dental plans, none of the plans will pay for certain services. Next, to control costs, insurance companies may combine two dental procedures into one. This is referred to as bundling, and it may reduce your benefit. Downcoding is another cost-control measure wherein the plan changes your dentist’s procedure code to a less complex or costly procedure code.

Lastly, your plan may have a LEAT clause, which stands for least expensive alternative treatment. Essentially, insurance may only cover the least expensive way to treat a condition, though such a route is not necessarily the best way.

At East Portland Dentistry, your Portland dentists of choice, we are sensitive to our patients’ financial concerns and wish to demystify the insurance process. We encourage our patients to “open wide” and ask questions both about treatment and cost.