Payment & Insurance

In many cases, the money patients receive as payment for services from insurance companies is the same for “out-of-network” dentists as it is for “in-network” dentists. For instance, if your insurance plan has a $1000/year benefit, you will likely get a $1000 benefit whether you use an “in-network” or “out-of-network” dentist. “Out-of-network” dentists are free to use the materials and dental labs that are ideal for each service without being constrained by contract terms with dental insurance companies.

Each plan will have a listed set of procedures that are either “possibly covered” or “never covered”. (Note: Dental Insurance calls “possibly covered” procedures “covered” but we know better.) If your dentist diagnoses a need for a service that is “never covered”, your insurance company will not even consider whether or not they think you need the service; they will always deny it.

In other words, if you grind your teeth and need a retainer at night to keep you from breaking teeth in your sleep, and your insurance lists retainers as “never covered”, they don’t care whether you need it or not. They won’t pay for it. Procedures that are “possibly covered” are usually listed in insurance manuals as “covered procedures”. More aptly named “possibly covered”, these are services that your insurance will review according to their regulations and decide whether they want to cover it or not.

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.)

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.