Ask the Dental Experts

Friday, October 9, 2009

Dental Insurance Benefits

There are some terms used to describe dental insurance benefits that you need to know. Understanding the legalese that surrounds the insurance industry can go a long way toward helping you choose the right policy.

Preauthorization
This is also known as predetermination of costs. This type of coverage involves having your dentist submit a treatment plan to your provider. Your provider then looks at the proposal and determines what benefits they will allow. This decision is based upon your eligibility, covered services, and the limitations of your dental insurance benefits plan. The intention here is to prioritize and plan your dental treatment and to allocate funding in advance to best match your coverage to cost.

Coordination of Dental Insurance Benefits
If you have dual coverage with a spouse, coordinating benefits maximizes the coverage you get from both dental insurance plans.

Non-duplication of benefits
Some people do not like it when you coordinate benefits. They have a clause in the policy that prohibits overlap if you are covered by two plans.

Annual Dental Insurance Benefits limitations
Insurance companies are for profit organizations and therefore do not want to spend an unlimited amount of money. They place annual limits on the dollar amounts, treatments, and procedures you can receive.

Least expensive alternative treatment (LEAT)
Dental insurance benefits tend to favor the least expensive treatment options. You can always choose a more expensive treatment if you are willing to absorb the difference in cost.

Premium adjustments and Re-evaluations
It is necessary that both you and your employer lobby your insurance company to regularly re-evaluate premium levels. This needs to be done in order to ensure that the UCR or Table of Allowances that the company bases its payouts on are in line with actual fees charged by dentists in your area.

Peer Review for Dispute Resolution
This is a system that exists for resolving the disputes between patients, third parties, and dentists. If a case goes to peer review, your individual records, treatments and results are thoroughly examined before a resolution is recommended. This usually resolves any disputes to the benefit of all parties.

How do third parties categorize the services your dentist provides?
There are basically four service categories your dental insurance benefits plan falls under.

Diagnostic
Diagnostic services refer to exams, x-rays, and other services that are used to evaluate your oral health and detect malfunction or disease.

Preventive
These are services that are intended to prevent decay and disease, such as dental cleanings, fluoride treatments and the application of sealants.

Restorative
When teeth become decayed or damaged, they must be repaired with fillings, crowns, inlays and onlays used to restore strength and functionality.

Discretionary (or elective/cosmetic)
These are treatments that deal primarily with aesthetic concerns and are usually considered optional by the provider.

Labels: dental insurance, dental insurance benefits, dental insurance covers, dental insurance plans

Wednesday, October 7, 2009

Dental Insurance Plans

It is essential that you understand your dental insurance plan in order to get a clear picture of the benefits it offers.

The first thing to know is the originator of your plan. There are various sources of dental insurance, all of which operate differently.

1. Insurance companies: Insurance companies are for-profit organizations that assume financial risk of your dental health. They process your claim whenever you have services rendered. Insurance carriers enter into a contract with either groups (normally companies) or with individuals. They offer a variety of benefit packages based upon the specific dental insurance plan.
2. Dental service corporations: These are non-profit organizations that negotiate and coordinate agreements for dental treatment for individuals and patient groups.
3. Self-funded insurers: Some companies will actually reimburse their employees for dental expenses accrued during the time of employment. These reimbursements are typically limited in both dollar amount and treatments covered.

One thing to be on guard about when choosing a new dental insurance plan is whether or not your new policy will allow you to continue to see your regular dentist. It all depends on whether or not you are investing in an open panel plan or a closed panel plan.
An open panel plan will allow you to keep your family dentist, or to choose any other dentist you wish. A closed panel plan will allow you to see only dentists who are on contract with their program.

Two types of closed panel plans exist:
1. PPO (Preferred Provider Organization)- You can choose a dentist in your area who has agreed to charge less than his or her regular fee. If you do not choose a dentist on the list, you have to pay a higher portion of the bill.
2. EPO- (Exclusive Provider Organization): You must choose a dentist from a limited number of professionals who have agreed to charge substantially less for their services. The EPO may even have these professionals on some sort of salary. The majority of dentists do not participate in these plans, so your options here are very limited indeed. Getting to a specialist can be a real challenge in the event you need cosmetic dentistry services or special care. You are also limited in terms of how much care you can receive in a year.

Of course, all dental insurance plans seek to regulate how much dental care you can receive in a year and how much they are willing to pay for that care. Understanding how your benefits and payments are calculated is vital to choosing the right policy.

Usual, customary and reasonable (UCR): These fees are paid directly to the dentist and are based on a schedule that was set decades ago. These fees are quite low compared to normal dental costs. The disadvantage to this is you pay more out of pocket. The advantage is you can see any dentist you wish.

Table or schedule of allowances: This is similar to a UCR but more restrictive. There may be times you cannot choose your own dentist and may not get quality care you prefer. You may also have difficulty finding a specialist. A maximum dollar amount is assigned to each service regardless of regional cost. These fees can vary according to inflation, so be very careful before choosing this plan.

Capitation (also called per capita): This type of dental insurance plan predetermines what level of benefits you will need in a year and agrees to pay for those only. If you get treatment for something outside of the plan, you end up paying for it. The quality of care is often compromised with this plan, because if the dentist is underpaid for his or her services, there may be a temptation to under-treat the condition.

Labels: dental EPO, dental insurance plans, dental PPO