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How Dental Fees Are Set

If you're like most people, you probably don't pay that much attention to your dental benefit plan. You know you've got one, but somehow reading that big book that outlines the details has never made it to the top of your list. Ever wonder what it says?

In a nutshell, it tells you that your employer has contracted with an insurance company to pay for a predetermined portion of your dental care. It also outlines what dental services your employer has agreed to pay for and which dentists you can see.

It's important for you to read and understand your benefit plan. Keep in mind, though, that your insurance plan might not adequately provide for all of your dental treatment options. Only you and your dentist can decide what treatment best meets your dental needs, so don't rule out a procedure if your insurance won't cover it.

How are my dentist's fees determined?

Your dentist charges you a fee for the actual treatment performed and the time it took to complete, as well as a portion of the office overhead. Your dentist's overhead includes the cost of having quality staff, state-of-the-art equipment, modern dental materials, current infection control procedures, and continuing education to ensure that your dental team is up-to-date on the latest techniques.

How are my dental benefits determined?

Your benefits depend on the contract your employer has set up with the insurance company. Your employer pays the insurance company a specific premium, which the insurance company in turn uses to pay for your care. The higher the premium your employer pays, the less you will be expected to pay out of your own pocket.

When you're looking at the description of your dental plan, check carefully to see which services will be fully covered by your insurance and which ones will require you to "co-pay," or shell out your own cash for some or all of the services.

Most insurance plans use a "usual, customary and reasonable" (UCR) fee schedule to decide what portion of the dental treatment it will pay for.

  • A "usual" fee is the fee that individual dentists usually charge for a specific procedure. This fee varies from office to office.
  • A "customary" fee is the highest fee level your dental plan administrator decides it will pay for a specific dental procedure.
  • A "reasonable" fee is the amount your dentist charges if a procedure has special circumstances that justify a higher fee.

A UCR plan will pay either a set percentage of the dentist's fees, or its "reasonable" or "customary" fee limit - whichever is less. Because these limits are set by your employer's contract with the insurance company, they may or may not reflect the actual costs of dental care in your area. If a plan's "customary" fee limits are unrealistically low, you will end up paying a larger portion of the treatment costs.

Again, the amount of reimbursement depends on the specific dental plan that has been purchased. The insurance company can set limits on the amount paid for any dental procedure. For example, if the plan pays at the 80 percent level, that means 80 percent of the UCR fee as determined by the insurance company, not the actual fee charged by the dentist.

Why is there such a big difference between the amount insurance companies will pay?

There are no standards for determining UCR fees. Even if two insurance plans are housed in the same building and owned by the same company, the plans' administrators might come up with different UCR rates for the same procedure.

For illustration's sake, lets say 40 people from your town went to see their dentists on the same day to have a missing tooth replaced and those dentists all charge the same price for the procedure. When the bill arrives, each patient is charged an amount that varies by as much as 136 percent.

That's UCR rates at work. What you pay depends entirely on your employer's benefit contract and your plan administrator's UCR fee structure.

What should I do if I get a letter from my insurance company?

If you get a letter from your insurance company stating that your dentist's fees are above its UCR rate, talk to your dentist. Your insurance company might have out-of-date information, or might not have considered local factors when it set its fee schedule.

If after talking to your dentist and your insurance company you are still not satisfied, talk to your employer or union to let them know that the mask your dental benefit plan is hiding behind didn't fool you for a second.

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