Dental Insurance FAQ

The answer is probably! We are a Preferred Provider (PPO) for Aetna, United Concordia, Blue Cross Blue Shield of NM, TX and a few other states, Cigna, Delta Dental, Guardian, MetLife. We will also file any insurance on your behalf. But here’s the most important part: did you know that most PPO dentists who “take” your dental insurance accept the exact same fee for service? The insurance company pays the doctor a set amount and the patient, when applicable, pays a set amount. That’s why it’s so important for you to select a dentist and a dental office that meets your personal needs. When you have insurance, you often pay the same price no matter which PPO office you select, so why not pick someone you trust in an office where you feel comfortable?

Unfortunately, some insurance companies simply do not pay dental providers enough to cover the cost of materials and labor for a procedure. If you’re having a hard time finding a dentist that “takes” your insurance you may have one of those low reimbursement companies.

PPO means Preferred Provider Organization. Dentists and other healthcare professionals simply fill out forms and sign a contract stating that they will accept a certain fee for each service performed. For example a doctor may say a procedure costs $150, but the insurance company says it’s going to pay $100 for it. Dentists and other healthcare professionals who are PPOs or “in-network” accept this discounted fee in exchange for being listed as a PPO for that insurance company. It’s great for patients because it helps to keep costs low. It’s great for doctors because they get an opportunity to see new patients!

No. The patient and the insurance company truly receive the most benefits in a PPO situation. As a dental office, we’re just thankful to be on the list of options for our patients with insurance. You could truly go anywhere for your care. We’re deeply honored each time a patient chooses us.

Dental insurance generally offsets the cost of treatment, but doesn’t pay for it entirely. On average, dental insurance covers 80-100% of preventative (cleaning, exam and x-rays), up to 80% of restorative (minor fillings) and up to 50% of major work (crowns and bridges). We do our best to estimate your portion of the payment before you leave our office, but with literally hundreds of insurance companies and thousands of individual plans it’s simply impossible for us to know all of them. That’s why it’s so important for you to know your plan and take charge of your health!

We do our best to estimate your out-of-pocket cost before you leave our office. It’s always our goal to be as accurate as possible about what you owe for your visit. As much as we try to be experts on every person’s dental insurance, our real expertise is in dentistry! Please remember that we are a PPO for nine insurance companies and each company has dozens of plans that an employer can purchase for an employee. We encourage all patients to be advocates of their own health. But rest assured that we will do everything in our power to make sure you get the full benefit owed to you by your insurance company. Here are a few reasons why you may have received a bill:

• Your insurance plan paid a lower percentage than expected for the procedure.
• The treatment you needed was not covered by your plan.
• The insurance company decided you did not need a procedure that the doctor identified as necessary or downgraded a procedure code.
• You have not met your deductible.
• You have not reached the end of your plan’s waiting period and are ineligible for coverage.
• You’ve maxed out your plan (used up all your benefits on other procedures) and no longer have coverage until the plan resets next year.

Think about it like this. Pretend that your insurance card is like a debit card. If the procedure is covered, there’s money in the bank to pay for it. You wouldn’t spend money without knowing it’s there waiting on you in your checking account. Insurance is similar. If you know your plan, you will know whether the funds are there to pay for services.

But insurance can be really confusing. That’s where we come in. We will take the time to explain your benefits to you as best we can. It’s why we have so much information on our website. We want to educate you so that you can be empowered to take charge of your health and get the full benefit of the insurance you work hard to pay for.

The time for a dental insurance carrier to process an insurance claim varies. At least 38 states have enacted laws requiring dental insurance carriers to pay claims within a timely period (ranging generally from 15 to 60 days). If you want to file a complaint about a delayed payment, contact the insurance commissioner in your state. They want to know if your insurance company does not pay within the period allowed by your state law.

Our doctors diagnose and provide treatment based on what you need, not based on what your insurance covers. Some employers or insurance plans exclude coverage for necessary treatment to reduce their cost. If you’re having trouble affording your dental care, ask us! We offer financing options and if the procedure allows, we can sometimes spread out treatment a little to help you afford it.

No. This is insurance fraud. We are contracted with insurance companies to provide 100% honest information, otherwise our PPO relationship would be cancelled and our dental license revoked. Not to mention that we believe in providing honest, quality care because of who we are and what we believe. Dishonesty is never permitted in our office.

We will do our best to answer all of your questions, however, a call to your insurance company, a visit to their website or a meeting with your plan administrator (often your human resources department of your employer) is a great step to fully understanding your insurance coverage. We encourage you to learn as much as you can about your insurance and take charge of your health!

Your insurance company can provide you with a breakdown of your dental benefits, but there are six key things to ask about:

• Plan Year: Does your insurance follow a normal calendar year? (Jan. 1- Dec. 31) If not, what month and day does your plan year start and end?
• Yearly Maximum: What is your annual maximum benefit dollar amount?
• Waiting Periods/Age Limitations: Are there any waiting periods for benefits to begin or age limitations?
• Frequencies: How often does your plan cover cleanings, exams, x-rays, fluoride, and sealants?
• Composite Restorations: Does your plan reduce coverage to the rate of old-fashioned amalgam restoration material or does it cover up-to-date composite fillings?
• Percent Coverage: What percent does your insurance cover for:
  • Preventative/Diagnostic?
  • Basic Restorative?
  • Major Restorative Treatment and Prosthodontics?

Once you have this information, bring it to us! It will help us understand your plan as well and help us better estimate your out-of-pocket expense.

Most employers distribute new insurance cards occasionally without changing the plan, but sometimes a plan changes without the distribution of new cards or a new group number. It’s always best to ask. If your plan changes or you have a new insurance carrier, call us to let us know about these changes right away. We can update your chart before your next appointment, saving you time waiting and filling out forms in the office. Plus, this will increase the accuracy of your estimated expense the next time you visit us!

We highly encourage you to call your insurance company and ask. And be sure to let our business staff know about any dental appointments you have had at another office during the benefit year. This will help to ensure you receive your full benefit at upcoming appointments.