For instance, let’s say you need a filling done for a cavity, and your insurance lists fillings as “covered” (or more accurately, “possibly covered”).  Insurance has the right to say that they will pay for part of that filling but that they mandate it has to be a silver filling even though it’s going on your front tooth.  (Yes, this happens.)  Tooth-colored fillings are more expensive and if you opt not to have a silver front tooth, then your insurance may not cover that at all.  Do you have hereditary bone loss and need cleanings four times a year instead of twice to prevent teeth from falling out?  Unless you have had gum surgery in the last year (and it’s a goal not to have it more than once in a lifetime) then your insurance may not cover more than two cleanings a year.  You get the idea.  (By the way, there aren’t any “always covered” procedures.  Sadly.)

IV.  My dental insurance doesn’t pay 100% of my covered procedures?

PPO insurances almost always pay only a percentage of each covered procedure.  Let’s walk through a scenario for a patient who has a dental PPO and needs a crown on a tooth that is broken.  Once the tooth is repaired with a crown (and not beforehand), your Humble Tx dentist can submit a claim to the insurance company that says, “I did this crown to splint the tooth because the tooth was broken.”  The dentist sends documentation in the form of clinical notes, x-rays, pictures, measurements.  The insurance company reviews this information and accepts this as a covered benefit for the patient.  That means the patient doesn’t owe anything for that crown, right?  Nope. 

The crown is covered at 80%.  So that means that the crown that cost $1000 is now only $200 for the patient, right?  Nope.  This insurance only reimburses for the least expensive solution which is a metal crown which costs $500, of which they will pay 80%, or $400.  The patient got a porcelain tooth-colored crown, which most of us would want.  So that means that the patient will pay the residual $600 of the $1000 charge for a porcelain crown.  Feeling discouraged?  Your doctor deals with this nightmare daily to get you the best coverage they can and there’s not a thing your doctor or you can do about it. 

V.  Shouldn’t my doctor have known beforehand that my insurance wouldn’t pay for this procedure?

Most insurance companies provide limited information to dentists before claims are made.  All the dentist knows in most cases is what category the treatment falls into (either “possibly covered” or “never covered”).  Even when dentists send a document to insurance companies before any treatment is rendered (called a “Predetermination of Benefits”), this document is no guarantee that insurance will accept the treatment (and even states so on the document itself, rendering it a veritable total waste of time unless it’s a required hoop to jump through for your policy in order to get claims through). 

Just to determine what category your treatment falls into (“possibly covered” versus “never covered”) your dentist’s staff has to wait nearly an hour in many cases on hold on the phone with a representative.  This process is done before your dental appointment so know that when you arrive for your new patient visit, we are excited to see you and have already spent the time to verify your potential benefits so you can make an informed choice in your dental care (or as informed as is possible based on limited information released by insurance companies). 

IN SUMMARY:

What’s the bottom line? PPO or HMO or no insurance? “In-network” or “out-of-network”?

Unless you are comfortable with your providers being selected for you, stay away from dental HMO plans.  If your company offers a dental PPO plan at a yearly premium that is far less than your annual benefits, that policy might be a good option (i.e. don’t buy a plan for $900/year that only has $800/year in benefits.  Yes, this happens.). 

Be aware that “in-network” providers will be working with a limited reimbursement rate and that may risk the quality of care you receive. 

“Out-of-network” providers are able to provide services at reimbursement rates that they feel comfortable can cover quality materials and patients who seek care from “out-of-network” providers usually receive the same yearly benefits as if they were seeing “in-network providers”.  In other words, if you get $1000/year in benefits, you get that $1000/year no matter whether you see a “preferred provider” or not. 

What can I expect with Houston Dental Implants, Family Dentistry, Oral Surgery & Periodontics in Humble, Tx?