Being a PPO dentist I wish I had a dime for every time a patient asked ‘Does my insurance cover this?’ If I did, I could buy 10 new handicap ramps since ours was stolen from our premises this year (true story)! At a time where words can have different meanings to different people I want to dissect what a patient could be asking when they say, “Does my insurance cover it?”
From my experience patients are asking really 2 things. Firstly they are asking, is it 100% paid for by insurance? Secondly, will our office guarantee that? What patients do not realize is that neither the patient nor the provider have ultimate control on what the insurance will pay for (if paying for anything at all). The insurance ultimately controls this AFTER the services are completed. The insurance company pays what they believe they are liable for and the patient pays what is not covered to the doctor or the doctor is obligated to write off some of these services depending on the agreement. Both the patient and provider sign contracts with the insurance company agreeing to these terms. So why are patients asking providers, “Does my insurance cover it?” when the truth is we do not know for sure until after the work is done and the insurance process the claim? We are not the insurance, but the provider, who does not have the authority to guarantee payment.
One reason I believe this crazy cycle of confusion exists is from something insurances are producing called an EOB. An EOB is an “ESTIMATION Of Benefits”. Key word here is ESTIMATION. Patients read their EOB’s and they are confused into believing these estimates are guarantees of coverage. I am listing some common scenarios I have experience where there is not a 100% guaranteed coverage patients are assuming.
1. Deductible – the service rendered has an unmet deductible. People are shocked this includes emergency visits, x-rays, and most dental work.
2. Percentage coverage – some services are only covered at a certain percent of the fee used. We are seeing now even cleanings are being covered only 90%.
3. Maximum allowance – the patient has used the $1000 they were allowed to use for the year and the rest is out of pocket. This $1000 can be hit after 1 molar root canal and crown.
4. Fee used to calculate coverage – If insurance is out of network the fee used to calculate coverage is usually a lower fee than the provider fee. So 80% coverage can quickly turn into 50% coverage.
5. Frequency limit – After one thing is done it can’t be done again for a fixed amount of time. Examples include 2 exams a year, 1 full mouth set of x-rays every 5 years, Bitewing x-rays 1x/year, fillings on same tooth 1 every 2 years. If these limits are exceeded the insurance can deny coverage and the patient must pay the amount due.
6. Downgrades – The insurance has the right to pick the least expensive option and use that to calculate your benefits. (All metal crowns vs. porcelain crowns, silver fillings vs. white fillings, denture versus implant, etc).
7. Coverage is terminated or expired – Employers are eager to save on dental insurance plans. I have had employers cancel plans retroactively (so there was no way for us to guarantee active coverage unless time travel was possible).
8. Tooth exclusion or missing tooth clause – This is when the tooth was missing prior to insurance being activated. (Common with implant or bridge coverage denials).
9. Non-covered expense – there are many procedure codes in the CDT system. Most insurances only cover a basic portion of these. The patient is expected to pay non covered expenses out of pocket.
10. Non-restorable denial – An insurance company can deny coverage based on a disagreement on whether they believe the procedure should have been done due to restorability. This is hard to believe as they have not examined the patient, but I have seen this happen in our office.
11. Prior billing errors – Some dentist offices have incorrectly billed extractions or other work. When the patient goes to a ‘better organized’ office and the correct teeth are billed the insurance can deny payment based on inconsistencies with prior billed services (happened to us as well!).
12. Primary and secondary issues - If your dentist is in network with your secondary but not in network with your primary insurance the secondary can deny coverage based on incomplete processed primary coverage. Insurance law dictates which insurance is your primary and secondary insurance not the dental office. It really is the patient's reponsibility to notify the dentist of all insurances they are participating with.
13. Insurance criteria for coverage – Periodontal scaling or root planning can be denied if the insurance does not believe the pockets are big enough or there is not enough bone or attachment loss. Are we then supposed to wait for the gum disease to get worse?
14. Limit on replacement coverage – Insurances will demand past dental records of the patient prior to coverage of a failing bridge. They want to see records showing the bridge was done more than 5 years ago. It can be difficult to obtain these records and also can significantly delay treatment.
15. Out of network or non-participating – some of our patients freely change insurances mid treatment and even within their own Insurance carrier during open enrollment (going from PPO to DMO) and end up with no coverage since we do not participate with DMO Plans. This is very difficult for a dental office to catch and should be the patient’s responsibility to inform the office if they are going to make any changes to their insurance plan.
16. Lab surcharges - patients have the expectation that the fees the insurances use to calculate coverage will assume any upgrades to the quality of dental care the patient or doctor is choosing to complete treatment. Dental implant restorations done in the anterior can result in black triangles, metal showing on areas not wanted, and poor access if the implant screw get's loose. These problems could and can be solved with upgraded options in restorative implant dentistry. I make sure my patients are informed of the estimated costs of these upgrades so there are no surprises of course. I also make sure the surcharge are in fact a devation from basic lab costs.
After reading this you should be overwhelmed! Well I guess this is really the point. Now when a patient asks ‘Does my insurance cover it?’ we hope they are implying that we have 20-30 minutes to grab a cup of coffee and discuss it with them. Otherwise we hope that they ask, ‘What is an estimation of benefits? We can answer that in 5 minutes after looking up some of their information but it is only an estiamtion. I recommend patients ask for ‘estimation if covered’ and ‘estimation if not covered’. This at least gets the patient a worst case scenario before moving forward with treatment. Also if time is not an issue for you ask the office if a predetermination can be done to get more specifics on estimates for work that may cost in excess of $800. This is a very reasonable request.
Dr. Maq Serang, DMD
CEO, Serang Dental Associates