Financial and Insurance Information
Patients often have questions regarding insurance and endodontic care. We have prepared the following answers for you.
Dental Insurance FAQs:
Does my dental insurance work the same way as my medical insurance? Dental insurance is not like health insurance. Dental insurance is based on a contract between the employer (or plan sponsor), the insurance company and you, who bears full responsibility for settlement of your financial obligation to our office. Most contracts have limits and/or various degrees of co-payment.
What is my maximum coverage per year? The maximum cumulative coverage for a “benefit year” for most dental plans is between $1,000 to $1,500. Dental insurance is rarely a “pay-all”; it is only an aid. This is often a surprise to the patients, because regardless of how much dental treatment they may need, the dental insurance company’s responsibility is usually capped at a relatively low amount.
What is a deductible? A deductible is the set amount you must pay before your insurance coverage begins. Most dental insurance has deductibles between $50 and $100. Please check with your insurance carrier to determine your deductible amount.
What is the percentage that my insurance will pay for your services? We will make every effort to provide you with a reasonable estimate of what your plan is likely to pay. Unfortunately, because of such things as maximums, deductibles, non-covered procedures, etc. calculating the exact coverage is impossible. Dental plans may cover as little as 0% or in rare cases as much as 80% of dental services.
How much does a root canal cost? Each endodontic case is different and fees vary accordingly. Once an examination and consultation is completed, we will be able to tell you the fee and an estimate of how much your dental insurance will cover. Because dental insurance covers only part of the root canal fee, you are responsible for paying the remaining balance.
Why was my benefit different than what I expected? Many plans tell their participants that they will be covered “up to 80 percent or up to 100 percent,” but do not clearly specify plan fee schedule allowances, annual maximums or limitations (such as only 2 exams per year allowed, or 1 panoramic X-ray in 5 years). It is rarely covered at 100%. The amount a plan pays is determined by how much the employer has paid for the plan.
In addition, your dental benefit may vary for a number of reasons, such as:
- You have already used some or all of the benefits available from your dental insurance.
- Your insurance plan will pay only a percentage of the fee charged by your endodontist.
- The treatment you needed was not a covered benefit.
- You have not yet met your deductible.
- You have not reached the end of your plan’s waiting period and are currently ineligible for coverage.
Why can’t you tell me exactly how much I will owe you for the treatment? At the time of service, your portion of the payment responsibility is only an estimate. Our office will perform a benefit check to assess your benefits under your plan as well as complete the dental portion of your claim form and submit it on your behalf. The amount of the precise financial responsibility is determined by your dental insurance company after the claim has been filed. A final statement is then issued to you. We recommend directing questions about your claim to your insurance company.
Why isn’t the recommended treatment a covered benefit? Your treatment plan is individually tailored, and is not based on your dental insurance benefits or lack of benefits. Some employers or insurance plans exclude coverage for necessary treatment as a way to reduce their costs. Therefore, not all endodontic treatment will be covered through your insurance plan. Some endodontic services (such as CBCT imaging for most dental plans) may be excluded. While we want to provide you with the highest possible quality of care, your dental insurance may cover only very basic services. The type of care you receive from your office is based upon our professional judgment and years of experience and not the coverage you receive from a dental plan. We do not believe it is in your best interest to compromise any recommended care in order to accommodate your insurance program.
What is a dual coverage? This means that you have coverage from more than one dental plan. We will submit claims to both primary and secondary carriers. Some plans have a non-duplicate of benefits clause.
“In-Network” vs. “Out-of-Network:” If we are “in network” with your insurance company, this simply means we have a contractual agreement with that insurance to only charge an agreed fee for the procedures that they cover. The insurance company will then pay the appropriate percentage of that fee. If we are “out of network” with your insurance company, we do not have a contract with that insurance and you are fully responsible for what our office charges.
What happens if I used all of my benefits on my insurance? Once your annual maximum has been reached, the insurance company will not provide additional benefits for any dental service until the renewal period. Each insurance policy is different. Please read your policy so that you are aware of your benefits and limitations. Your claim will be filed immediately, and benefits are expected to be paid within 30 days. The filing of an insurance claim does not relieve you of timely payment on your account. You are responsible for any amounts your insurance company chooses not to pay, for whatever reason. Should questions arise regarding your dental insurance benefits, it is best for you to contact your employer or insurance company directly. We will gladly provide all pertinent information to you at no charge.
What is a “UCR” and how is it determined? “UCR” is the term used by insurance companies to describe the amount they are willing to pay for a particular endodontic procedure. There is no standard fee or accepted method for determining the UCR and the UCR has no relationship to the fee charged by our office. The administrator of each dental benefit plan determines the fees that the plan will pay, often based on many factors including region of the county, number of procedures performed and cost of living.
How do I know what my payment portion will be if my insurance does not cover the entire fee? Your payment portion will vary according to the UCR of your plan, your maximum allowable benefit and other factors. Ultimately, the patient portion is not known until the insurance check has been received by our office.
How do I understand my Explanation of Benefits (EOB)? Your Explanation of Benefits (EOB) contains a wealth of information. The EOB identifies the benefits, the amount your insurance carrier is willing to pay and charges that are and are not covered by your plan. The statement includes the following information: UCR, co-payment amount/patient portion, remaining benefits, deductible and benefit paid.
What if I still have questions? Many questions that you have may be best answered calling your insurance company directly. While we will do our best to answer all your insurance questions, please keep in mind that there are many insurance plans available and that your employer chooses your plan and your benefits. If you believe your benefits are inadequate, you may want to discuss the matter with your plan administrator and explore appropriate alternatives.
We are glad to bill insurance on your behalf as a courtesy so that you will not have to pay for your entire procedure in full on your visit. However it is your relationship with the Insurance Company and any balance would be yours if insurance did not pay in full.