Despite our commitment to maximize and aid patients with reimbursement through their dental insurance provider, it is ultimately the patient’s responsibility to understand the specifics of their policy as well as the differences between dental and medical insurance.  A common misconception many patients share is that dental insurance covers 90-100% of dental fees.  In reality, most insurance plans cover only 30-80% of the cost and in some cases, dental insurance reimbursements are lower than the actual costs incurred by the patient.  This typically happens when the insurance carrier claims the doctor’s fees exceed what is considered reasonable, customary, or usual.

Each insurance company sets their own schedule and will differ on what fees they consider reasonable.  This variation in reasonable fees occurs because each provider bases their fees from claims they process.  Often, this data can be several years old, and fees are typically set to ensure the insurance provider nets a profit of 20-30%.  In essence, this is the insurance company suggesting your dentist overcharged you instead of sticking to their responsibility to honor your claim.  What insurance ultimately pays out will depend on the specific policy, how much coverage you or your employer pay for, and any contractual agreements between your employer and insurance company.

The primary goal of insurance companies is to make money.  As such, the more they pay in claims, the less profitable they are.  Because of this, it can be difficult to hold insurance companies accountable for a claim.  A common tactic insurance companies employ to avoid or delay payment of a claim is to state information necessary to process the claim was not received.  This grants them 45 days to delay paying the claim.