We have experience with all types of dental plans and can work with most of them.  In general, if you  are not required by your plan to go to a particular dentist we can help you.  As ethical dentists our responsibility and mission is to provide you with the best care possible.  The financial concerns you have because of Insurance company restrictions and limitations on treatment must be addressed, BUT,  they should not prevent you from hearing all options available to you, and allowing you to choose the course of treatment that is best for you.

We can help in several ways:

We will explain the treatment cost and help you discover what your insurance company is likely to pay before initiating treatment.

Dental insurance is a complex issue, and just to make it more interesting, each employer can have more than one plan available to its employees, and each insurance company offers a large variety of options - so determining what benefits you have for a particular procedure can be a challenge. 

We subscribe to a service which tracks insurance benefits at as many area companies as possible, and provides us with monthly computerized updates on benefits available under the various plans.  We use this information to make an in office estimate of your benefits so you can start treatment without unnecessary delay.

If your plan allows it, we can preauthorize your treatment.  This involves sending an itemization of the treatment you need to your insurance company along with supporting x-rays and narratives for their review.  After some period of time (legally they have 60 days) they should respond with a form which states what they estimate their liability to be (how much they will pay).  Their response is not a guarantee of payment.  They don't have to honor it - but they usually do.

CAUTION  Many preauthorizations are misleading.
Insurance companies will often recode or change the procedure that the doctor and patient have specified.   Some Examples:

1. Insurance companies will combine codes together and pay a lesser amount.  If a tooth has two small areas of decay which are not connected the proper treatment is to restore the tooth with two small fillings preserving as much of the tooth as possible.  If a claim is made for two small fillings on the same tooth done at the same visit, the insurance company will often change the code to a single larger filling or disallow the second filling altogether.  The only way to get paid correctly is to make two visits on different days, have anesthesia twice, and undergo the procedure twice.
2. If you want an esthetic white filling on a back tooth the insurance company may change the code and only agree to pay the amount they would have paid for a similar size silver filling. -  Or -  they may change the code for the standard Porcelain fused to Metal crown to Full Cast (all metal) crown on molar teeth, and pay less because they don't allow benefits for "cosmetic" white crowns on the back teeth. 

3. Most plans reserve the right to provide benefits for an "alternative less expensive procedure" at their discretion.  These are financial decisions made by insurance company personnel without examining or even speaking to you.  They are based on the insurance company's cost - without regard to which procedure is most appropriate or beneficial to you or your particular circumstances.  A disclaimer on the form will usually state that such decisions are not intended to prescribe treatment, but rather are used to meet contract limitations on insurance company liability for payment.  Most often they limit you to removable replacement teeth instead of fixed bridgework which is superior in every way.
    Bottom line - you are free to have the white filling, crown, or fixed bridge, but you must pay the difference in cost between the two fees.
If your insurance company applies such processing policies, their decision can be appealed - but it is ultimately their call and the doctor and patient can usually do little about it.
    Another example of benefit reduction is when your insurance says it pays 100% for preventive procedures but the "fine print" allows them to apply their "customary and reasonable" clause and pay 100% of a lower fee leaving you with a balance to pay.  This does not mean you were overcharged.  Insurance companies refuse to disclose the details of how they determine what their "customary and reasonable" fees are, or when they were last updated,  and there is no regulation in this area.  They can essentially use any number they want to.  Your best course of action in this circumstance is to ask your dentist what other similar plans accept as customary and reasonable to see if your insurance benefit is in line with other similar companies.

The main advantage to preauthorization is that such negotiations take place before you have to make a financial commitment.

The main disadvantage of preauthorization is that they can delay needed treatment for months while the paperwork is shuffled back and forth.  Meanwhile the problem can get worse, more damage to your mouth can occur, and you might need more treatment than was originally necessary.

Last modified: 05/03/04