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Frequently our patients ask us what their insurance will cover and, “Why doesn’t my insurance pay for this?” The following explanation was provided by the American Dental Association in 2009. We hope that it answers your questions.
Under a UCR plan, patients are usually allowed to see the dentist of their choice. These plans pay an established percentage of the dentist’s fee or pay the plan sponsor’s “customary” or “reasonable” fee limit, whichever is less. Although these limits are called “customary,” they may or may not reflect the fees that area dentists charge.
It may also be noted on your bill the fee that your dentist has charged you is higher than the reimbursement levels of UCR. This does not mean your dentist is overcharging you. For example, the insurance company may not have taken into account up-to-date regional data in determining a reimbursement level.
Why? There is no regulation on how insurance companies determine reimbursement levels, resulting in wide fluctuation. In addition, insurance companies are not required to disclose how they determine these levels. The language used in this process may be inconsistent among carriers and difficult to understand.
Your plan purchaser makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company. Even though the cost of dental care has significantly increased over the years, the maximum levels of insurance reimbursements have remained the same since the late 1960s. Many plans offer higher maximums that are comparable to rising dental care costs.
Your plan may want you to choose your dental care from a list of their preferred providers. Whether or not you choose your dental care from this defined group can affect your levels of reimbursement.
Your dental plan may only allow benefits for the least expensive treatment for a condition. For example, your dentist may recommend a crown, but your insurance may only offer reimbursement for a large filling. As with other choices in life – such as purchasing medical or automobile insurance or buying a home – the least expensive alternative is not always the best option.
Just like your medical insurance, your dental plan may not cover conditions that existed before you enrolled in the plan. Even though your plan may not cover certain conditions, treatment may still be necessary.
Your dental plan may not cover certain procedures or preventative treatments such as sealants that can save you money later. This does not mean these treatments are unnecessary. Dr. Han can help you decide what type of treatment is best for you.