Limited Dental Fee “Insurance” Benefits
by Lance Timmerman DMD
Again, I use the quotes over the word insurance because “dental insurance” is a myth. What I hope to explain here is the obligation of a balance when working with a third party benefactor. As time marches on, insurance in ALL forms is changing. As benefits morph into a different animal, it can be hard to keep up, yet SOME things are not NEW. Primary among the “old info” is the fee for the service in a dental office.
Dental Fees Are the Responsibility of the Patient
No matter what happens with dental benefits, the balance is the patient’s responsibility. Often dental insurance will imply they will pay a certain fee or a percentage of the fee, but if you look closely at the insurance paperwork, you can see the “loophole” or “out” that they give themselves. There is NO such thing as a pre-authorization (a binding contract), so submitting to dental plans in advance does only ONE thing: delay treatment. The result of submitting a claim in advance of treatment guarantees NOTHING, and it never has. The correct term is “Pre-Determination” and is only a “guide” or “suggestion” of benefits, but determination of benefits is done at the time of ACTUAL CLAIM OF SERVICE submission.
Dental Plans Lie
It is not unusual for a plan to determine in advance that there is a benefit for a procedure and then not pay when the procedure is done. More commonly, they simply pay LESS than anticipated. This does not mean that the dentist assumed all risk and with less revenue received they simply “write it off.” This means that the patient is responsible to pay the remainder. While some dentists skirt the law and commit insurance fraud by not collecting the patient portion or remaining balance, most dentists are honest and do NOT do this.
Patients Trust Insurance Plans More Than Doctors
It is a sad truth, but made clear daily, that patients don’t trust their doctors anymore. Very often they are told one thing or another by their plan that contradicts their doctor and they side with the plan. That is an individual choice to do so, and despite insurance plans losing lawsuits or “settling out of court” when caught lying to patients or damaging doctor:patient trust in an effort to extort a doctor to join their network, people continue to side with their plans. With the Affordable Care Act developing, people are taking a long and hard look again, but things change slowly.
Predetermination of Benefits Is a Waste of Time
Speaking from experience, predeterminations (“preauthorizations”) are a waste of time. As stated earlier, it merely delays treatment. Our experience includes “insurance” being wrong both ways. Once a plan said they would contribute $500 for a procedure and when treatment was done and the claim was submitted, our office got $125. Another time a predetermination said they would pay $400 and we ended up with $600. Why bother with submitting in advance?
Because the “insurance” plan knows that statistically if treatment is delayed more than 3 weeks (the amount of time to get a response for the predetermination) only 30% follow through with treatment. With such large holdings (insurance company investments) even just delayed treatment allows them to make millions of dollars while they wait to pay out a benefit
Frame Of Mind
The best way to deal with this is simply pay the entire amount charged by your doctor and anything that comes back from insurance is a rebate or benefit. There is no balance left owing the doctor and if you are not satisfied with the amount received you can work on getting more. Good luck. But the bottom line remains:
The balance owing the doctor is 100% the responsibility of the patient no matter what the plan benefits pay out.
Even if there is a contract benefit, if a contract limitation means the benefit won’t pay (crown redone in 5 years but plan won’t pay sooner than 7) this does not mean “free dentistry.” This means the service was rendered and the balance is ALL on the patient.