What To Do If My Dentist Does Not Accept Insurance? Well, you have a couple of options. You can: (1) negotiate with your dentist on the cash price, or (2) enroll in a true “PPO” plan that does not discriminate between in-network and out-of-network dentists
Full Answer
What should I do if my dental insurance won’t cover my needs?
It’s also assuming that you’re not in pain, and/or your dental issue doesn’t require treatment ASAP. You can also ask your dentist about a payment plan for the amount that your insurance won’t cover, or you may want to consider supplemental dental insurance coverage or a dental savings plan.
Is my dentist advertised on my insurance company’s fee schedule?
Not True. Your dentist receives a fee schedule, the insurance company’s fee schedule, at the time they contract. This gives the dentist a right to be advertised on the insurance company’s list of in network providers. Being “In Network” dictates the maximum fee the dentist may charge for treatment procedures allowed by the insurance company.
Does my dentist accept my insurance?
Then, your dentist might “accept” your insurance, but that does not equal being in-network. Dentists often charge whatever they like, and the local market will support because the insurance plan permits this billing practice. Dental plans do not all work the same way.
Should you schedule dental treatments that meet insurance maximums?
Don’t hesitate to talk to your dentist about scheduling treatments that meet your insurance maximums. For example, if your plan provides a year’s coverage starting in January and you need a root canal and crown that will cost about $3,000 you might be able to get $1500 worth of care in December, and finish your treatment in January.
Why are dental claims denied?
Incomplete or incorrect information on the dental insurance claim. This might seem like a no-brainer, but it's one of the more common ways that dental insurance claims are denied. It's pretty easy to misspell someone's name, input the wrong insurance number, or any kind of input error.
What is excluded in dental insurance plan?
All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes, dental coverage and medical health insurance may overlap. Read and understand the conditions of your dental insurance plan.
How do I write a letter of appeal for dental insurance denial?
I am writing, on behalf of [name of plan member if other than yourself], to appeal the [name of health plan and policy number] decision to deny [name of service, procedure, or treatment sought] for [name of plan member if other than yourself].
Can I switch dentists in the middle of a procedure?
You can be unhappy and end up switching dentists mid-treatment and yes, you can switch dentists in the middle of a procedure. You can do whatever you'd like with your health.
What are limitations in dental insurance?
Limitations determine how often a particular service is covered and are related to time or frequency (the number of procedures permitted during a specific period). For example, no more than two cleanings in 12 months or one cleaning every six months.
Which of the following is not a common exclusion for a dental expense policy?
All of the following are common exclusions found in dental insurance plans EXCEPT: routine oral examinations.
What should be done if an insurance company denies a service stating it was not medically necessary?
First-Level Appeal—This is the first step in the process. You or your doctor contact your insurance company and request that they reconsider the denial. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review” in order to challenge the decision.
How do you win dental appeals?
A proper appeal involves sending the carrier a written request to reconsider the claim. Additional documentation should be included to give the carrier a clearer picture of why you recommended the treatment and why you feel the claim should be reconsidered.
How do you argue with dental insurance?
Write a letter stating that you wish to appeal your dental insurance claim. Gather supporting documentation such as a letter from your dentist and your dental records as well as any correspondence with the insurer. Send the letter and documents to the address listed on your denial letter or explanation of benefits.
How hard is it to switch dentists?
Expect lots of paperwork, lots of information, and new x-rays. Your new dentist should want to get the most accurate picture of your dental health so that they can create a personalized, accurate dental treatment plan, but this process won't be overwhelming since you know it's coming.
Can dentists strike you off?
Your dentist can terminate your treatment if you miss your appointment without letting the dental surgery know. You may then need to pay again for a new course of treatment.
What happens to dental records when you change dentists?
You'll Have to Get the Dental Records Transferred Just like switching to a new doctor, your records have to transfer over to the new dentist. Many dentists will take care of this for you, but you may have to ask your old dentist for the records yourself.
Why does my dentist not accept insurance?
So, to answer the question, usually, a dentist does not accept insurance because he or she does not want to lock themselves into a fixed service fee.
What is a true PPO plan?
You might be thinking what is a “true” PPO plan when we just described the differences between the in and out-of-network of a typical PPO plan. A “true” PPO plan doesn’t have any network dentists. You can “truly” go anywhere and the plan will pay. ...
What is dental insurance?
It is actually a benefit provided by employers to help employees cover the cost of routine dental treatment. An employer will buy a plan (one of many offered) based on the amount of the benefit and the cost of the premium for the company or the employee. Most plans cover only a part of the total fee for dental services.
How much does an insurance dentist charge for an exam?
The insurance company typically allows 100% as payment for the procedure. It isn’t always what the dentist may charge. An insurance company may allow $60 as payment for an exam, but the office fee is $80. This leaves $20 that the patient is responsible for.
Is a non-covered procedure necessary?
Patients might believe that a non-covered procedure is not necessary, and the dental office team must be ready to explain why it is. Patients should be told, gently and appropriately, that coverage is not the sole consideration for accepting recommended treatment.
Is dental insurance the same as medical insurance?
There are as many different plans as there are contracts, and dental insurance is not the same as medical insurance. In fact, it’s not really “insurance” at all. A patient’s employer selects the plan and is ultimately responsible for the design of the contract. Each contract specifies what procedures are covered.
Can a patient with bad credit qualify for a loan?
Therefore, there’s no guarantee that your patient will qualify. Even if they do, the interest costs associated with paying down the balance over time might be prohibitive.
Do Medicare patients have dental insurance?
Recent surveys show that approximately 23% of Americans and two-thirds of Medicare beneficiaries don’t have dental insurance. For those patients, the cost of any dentist’s office visit — whether it’s for a simple cleaning or a more advanced procedure like an implant — needs to be paid out of pocket.
Why are dental plans so minimal?
Dr. Powell asserts that one major reason dental plans tend to be so minimal in what they cover, is because people don’t want to shell out higher premiums.
Why is dental care separate from medical care?
“The reason dental is separate from medical is that the nature of the risk is fundamentally different as is the deferability of the care ,” says Dr. Adam C. Powell, president of Payer+Provider Syndicate, a management advisory and operational consulting firm focused on the managed care and healthcare delivery industries. “If you’re having a heart attack you'll go to the ER right away. Dental problems can often wait and unfortunately often do. The problem may deteriorate, but often it’s not necessarily life-threatening.”
Does dental insurance cover dire issues?
Clearly the purpose of dental insurance is not to cover dire issues, but to prevent them — by encouraging regular maintenance. Dr. Powell likens dental plans to “Triple A for your mouth," highlighting that "it's not like car insurance [which covers catastrophes], but it includes a few free oil changes.”
Is dental insurance like triple A?
Dental Insurance Is Like ‘Triple A For Your Mouth’. Now, let’s say you do have dental insurance. That’s certainly more favorable than the alternative, but it’s hardly ideal. If you undergo a serious procedure, you’ll likely still be left with a hefty bill. “Dental insurance, unlike medical, is not regulated and it tends to be very constrained,” ...
Do dental problems wait for paycheck?
Yes, dental problems often do wait. Mine is waiting until my next paycheck (or three). But the argument that dental problems are less severe than “medical” ones doesn’t quite hold up, not when you look at the numbers of ER visits for which dental-related problems account.
Is oral health an outlier?
Despite it being a plainly medical issue, oral health has always been an outlier. Until the 1800s, dentistry was the domain of barbershops, practiced in the same chair and usually by the same guy who shaved your beard.
Can you have glaucoma with dental?
Such isn’t the case with dental. The oral cavity is a gateway to your body. A lot of stuff in the mouth can indicate kidney disease, heart disease, diabetes, HPV, cancer, etc.
What is dental eligibility and benefit allowance?
Eligibility and Benefit allowances are all the dentist can determine up front! The fine print exclusions, only the insurance company is privy to, are the reason dentists and the patient only get “Estimates” of coverage at the time of service. Here is another common insurance problem.
Is dental insurance trustworthy?
Yes, just like in all industries there are more trustworthy players than others. That’s true for insurance carriers and dentistry as well. If you have dental insurance it is a blessing to help you afford dental care. Most dental offices want to help you get the maximum benefit allowed under your plan.
Does Delta Dental represent insurance?
Many people mistakenly believe when they go to their dentist who is contracted (or in network) with an insurance company, (say Delta Dental), the dentist represents the insurance company. Not True. Your dentist receives a fee schedule, the insurance company’s fee schedule, at the time they contract. This gives the dentist a right to be advertised on the insurance company’s list of in network providers. Being “In Network” dictates the maximum fee the dentist may charge for treatment procedures allowed by the insurance company. (For example: The regular fee for a crown is $1000 but the insurance contracted fee is $800.00 and they pay 50% of that. The dentist then cannot charge more than the contracted fee for allowed procedures.)
Is insurance billing required?
Insurance billing service has kind of evolved into a “required service” due to the language, code submission complications and other details the patient is not in a position to understand or deal with in many cases. For these reasons, insurance billing services are not optional for a majority of clinics .
Do dentists have to bill insurance?
And remember (technically), no dentist is obligated to determine benefit allowances, bill your insurance, or deal with the problems that may come up to collect from the insurance company…In network or not! Except for the fact they want to get paid for services provided. Dealing with insurance is very time consuming and expensive for a dental clinic.
When did dental insurance start?
Dental insurance was first introduced in California in 1954, and quickly rose in popularity. By the 1970’s, these plans were widely available and usually provided a maximum annual coverage of about $1000 (which is still about the maximum today). The first plans didn’t distinguish between in-network and out-of-network providers.
Who owns dental insurance companies?
Dental insurance companies are owned by stockholders, equity firms and investment bankers for the purpose of making money. Unlike medical insurance companies that can run into unlimited liabilities with large claims dental insurance has a cap on the coverage. We will cover this in number 6 but as a matter of fact annual maximums have hardly changed ...
What was the deductible for dental care in 1970?
In 1970 dental insurance companies typically covered 100% of preventive services (with less restrictions than today) and 80 % of all other work with a $50 deductible on and of the 80% covered services. Today many insurance companies have deductibles as high as $200 but let’s assume it is $50. They may say your preventive is covered at 100% but in the small print it says you must pay the deductible first. So if a cleaning and x-rays comes to $200, you will pay $50. They will cover a 100% of $150, the remainder after the deductible. That would be the same as covering your preventative at 75%. That’s pretty sneaky in my books.
How much does insurance cover for cleaning and xrays?
Today many insurance companies have deductibles as high as $200 but let’s assume it is $50. They may say your preventive is covered at 100% but in the small print it says you must pay the deductible first. So if a cleaning and x-rays comes to $200, you will pay $50. They will cover a 100% of $150, the remainder after the deductible.
How long is a dentist on hold?
When a claim is denied or ignored, it is not uncommon for a dental employee to be left on-hold for over 30 minutes.
Why are dentists dropping out of PPO?
As they continue to lower and lower payouts, dentists are dropping out of the networks because they are uncomfortable with the care dictated by the insurance companies and are unable to run a business on the reduced fees. Don’t be surprised if one day the closest dentist in your PPO coverage is in the next state.
How many unpaid claims can a dentist have?
If a dental office has 16 unpaid claims you can see the dentist will have to hire someone full time to do nothing but listen to elevator music while trying to recover the money the office has already worked for.
How long do you have to wait to get dental insurance?
Dental insurance typically doesn’t provide immediate coverage for pre-existing conditions. With a new-to-you plan, you’ll usually have to wait six months for basic restorative services or a year for major restorative services.
What is pre-planning for dental?
Pre-planning helps you get the most from your dental coverage. Don’t hesitate to talk to your dentist about scheduling treatments that meet your insurance maximums. For example, if your plan provides a year’s coverage starting in January and you need a root canal and crown that will cost about $3,000 you might be able to get $1500 worth ...
What to do before purchasing supplemental insurance?
In general, the best thing to do is discuss funding options with your dentist before you purchase supplemental insurance. Your dentist may offer to discount the parts of your treatment plan that you will be paying for out of pocket. He or she may be a member of a medical insurance loan plan. Or your dentist may suggest that you consider ...
Do dental supplements have waiting periods?
Supplemental plans also usually don’t have waiting periods and restrictions on preexisting conditions. The bad news is that supplemental dental insurance policies also tend to be expensive, assume you’ll pay at least as much for your supplemental plan as you do for your primary plan.
What does "accept insurance" mean?
Accept insurance means they will happily cash claims checks as partial payments towards any amount billed for treatment. Participate means they signed a contract with the PPO plan and agreed not to charge above the allowed amount for covered services.
What is co-insurance deductible?
Co-insurance is a percentage of the allowed amount owed by the patients. A deductible is a member-paid amount for covered services before insurance kicks in each year (individual and family) Annual benefit maximum is the total claim payments the plan will make during the plan year (individual and family) Therefore, prepare to receive ...
Can a dentist balance a PPO bill?
PPO in-network dentists can balance bill patients above the copayment for approved services. It is standard industry practice for offices to seek reimbursement for the portions of the contracted amount that insurance does not pay.
Can dentists charge PPO?
There is no contracted amount because the provider did not reach a binding legal agreement with your insurance company to accept that figure as payment in full.
Can an out of network provider charge for a PPO?
On the other hand, out-of-network providers can charge whatever they want because the insurance contract does not bound them.
Do dental plans work the same way?
Dental plans do not all work the same way. Instead, the industry markets a wide array of designs that do not always include a contracted amount. [1] Table of Allowance (Supplemental) designs pay a set amount per procedure independent of what the dentist charges.
Can a dentist charge more than the insurance company approves?
Network Dentists Charging More than Insurance Approves. Dentists who are in-network with a PPO or EPO plan cannot charge more than allowed by the contracted amount when the insurance company approves the claim. This contractual figure is the limit they can bill patients for covered services. However, expect to fund beyond ...
What is HIPAA confidentiality?
As per HIPAA regulations, to confidentiality regarding your diagnosis and treatment, except when you agree to submit this information to others – such as insurance providers. (HIPAA is the Health Insurance Portability and Accountability Act, issued by the U.S. Department of Health and Human Services in 1996.)
What is a bill of patient rights?
By and large, a bill of patient rights is a mission statement that reflects the beliefs and goals of an association or practice with regards to its patients.
When did the patient rights revolution start?
The Patient Rights Revolution. The concept of patient rights came to the fore during the mid- to late-1990s, during which time the rise in HMOs was thought to potentially signal a lower quality of health care.
Credit-Based Options
Personal Loans
- Patients can also pay for the cost of their dental treatment through personal loans. These loans are often unsecured, which means that the patient does not have to put up any collateral for the lender to secure the loan. For that reason, the patient’s credit history will likely be the determining factor for this financing option as well. If a patient with a low credit score applies for a personal l…
Provider Financing
- Some dental offices give their patients the ability to apply for payment plans, made possible via third-party lenders. With this option, your practice can treat more uninsured patients. However, it also comes with the added burden of managing the loans, which usually requires the oversight of an internal finance department. Even when your internal ...
Flexible Pay-Over-Time Plans
- Pay-over-time providers like Healthcare Finance Directcan enable your practice to offer financing while minimizing the administrative burden associated with in-house lending. Unlike the other options listed, Healthcare Finance Direct looks beyond the patient’s credit score — they leverage a unique, data-driven risk assessment to determine the likelihood of a patient defaulting, based o…