Dental insurance is much different and should never be compared to medical insurance. It uses terms such as “yearly maximum” and “non-covered procedure” which tend to send patients into confusion and panic. This section is designed to help our patients understand their dental insurance benefits and how we can work together to get the most from your benefits while providing the quality periodontal care you deserve.
What is dental insurance, really?
Dental insurance is not like medical insurance. Medical insurance protects the policyholder and dependents in the event of serious illness or injury. Treatment is usually done while a small co-pay is paid by the policyholder. Dental insurance on the other hand is really a “dental benefit”. The type of insurance, amount and terms of the benefits are negotiated between your employer and the insurance company. Unfortunately, the goal of most dental policies is to provide basic dental care and usually only covers a specific list of dental services. Just because treatment is recommended does not mean the insurance company is going to cover it.
Yearly Maximum Benefit
A term synonymous with PPO insurance policies, the yearly maximum benefit is often the cause of most confusion. All PPO dental benefit plans have a yearly maximum. In this case the term “year” generally refers to a calendar year – January through December, but this can vary. Depending on your negotiated policy, the yearly benefit can be as little as $1000 per year. Interestingly enough, this amount has not changed much over the past 30 years while the cost of dentistry has risen considerably. The negotiated cost of any dental visit is deducted from that amount, less any copay. Once the insurance company has paid the $1,000 for dental care in a given year, the policyholder will not be reimbursed for any further dental care that same year, regardless of need. A yearly maximum is usually sufficient for those needing minimal dental care, but for those with extensive problems that require a more comprehensive treatment are often left without coverage for necessary procedures. Most of the dental care is paid for by the patient.
Covered and Non-covered Periodontal Care
Dr. Fotek will only perform procedures that are in your best interest and essential to your overall oral health. Unfortunately, there is the possibility that some or none of the periodontal procedures you need will be reimbursed by your dental benefit plan. You will be responsible to pay for any procedures your dental insurance refuses to cover. Our goal is to give you the optimal treatment we can in Jupiter. The goal of dental insurance companies is to provide a negotiated benefit for a select list of dental services only. The benefits your insurance company is willing to pay for your periodontal and implant care is often in no way connected to your specific needs to maintain optimal oral health. On a note, just because the specific periodontal service is on the select list of dental services, the insurance company is in no way obligated to reimburse you for the coverage.
A pre-determination policy does not authorize any payment by your insurance company for your procedures without their prior written consent. This step requires that the insurance company receives a dental treatment plan upon which they will decide to either pay or deny the much needed periodontal therapy. You will receive an “estimation of dental benefits” prior to treatment, which clearly identifies what portion of your periodontal care you will be responsible for. This process usually takes about 4 weeks. It is quite obvious that this pre-determination process delays treatment and may affect treatment outcome. We believe that helping our patients in Jupiter through the confusing dental insurance policies is part of our commitment to you. We always complete and submit the required forms in a timely manner and, when necessary, provide additional documentation. We will work with you to get paid by your dental insurance for your work that was rightfully deserved and much needed. We will continue to work with you to help you receive your maximum insurance benefit. Please remember that some insurance companies do process claims faster than others. If at any time you have questions on how your dental insurance benefits relate to your dental treatment needs, please ask us.
Dental Insurance Companies
Dr. Fotek is contracted and on the preferred provider list for many insurance plans. By seeing a dentist on the preferred provider list, that assures you are maximizing your dental benefits and that Dr. Fotek agreed to charge only the negotiated amount for the procedures performed. To find out if your insurance is covered with Dr. Fotek, please call our office at 561-292-0624 and we will be more than happy to verify your insurance benefits.