Welcome to Week 4! Now that you are more familiar with how dental insurance works, as well as some of the terms they use, let's show some practical examples for those of you who are visual learners.
Quick explanation of chart terminology:
Procedure: What was done.
Office Fee: How much we charge for the procedure regardless of insurance.
Ins Max Fee: The highest amount the insurance company will consider paying for the procedure.
Ins Appr Fee: The actual amount the insurance company will consider paying for the procedure.
Cov %: The rate at which the insurance's approved amount is covered by them.
Deductible: The amount of deductible applied to the procedure.
Write Off: The amount that our office writes off (doesn't charge or receive).
Ins Pmt: How much the insurance paid for the procedure.
Pt Pmt: How much you need to pay for the procedure.
Example 1: In Network vs. Out of Network for a 2 surface composite filling.
As you can see, you pay less in this example by going to an in network provider. A total of $124.35 is written off as part of the agreement between the dentist and the insurance company and you only pay 20% of the insurance maximum fee amount ($175.65). Out of network plans use our office fee as their highest allowable and then may have a lesser amount they approve to pay as above.
Example 2: In Network vs. Out of Network for a 2 surface composite filling which is downgraded.
In this example, you are getting the same procedure as in the first example, but the way the plans handle the filling are different. These plans are downgrading and approving a lower amount (an amount equal to the highest allowable for a silver filling on the same tooth). You still get the same adjustment (write off) as in network, but you have to pay the difference between their maximum fee and the approved fee, plus your 20% copayment.
Example 3: In Network (Plan 1) vs. In Network (Plan 2) vs. In Network (Plan 3) for a 6 month check-up
As you can see, all of the above exams and cleanings were covered at 100% which means there is no patient payment necessary. This example shows how different insurance plans negotiate different rates so even though you are in network, the amount that the dentist receives for the procedures can vary wildly.
Example 4: In Network vs. Out of Network for a crown.
This example shows the difference between in and out of network with a more pricey example. Crowns are generally covered at 50% so by lowering the rate to the negotiated fee, you save that extra money when you have to pay your copayment.
Example 5: In Network (Plan 1) vs. In Network (Plan 2) when maximum is reached.
Another way in which plans can differ is how they determine benefits for you after they've paid their full amount for the year. Even though both of the above plans are in network and should therefore receive a discount, some insurance plans have a clause that effectively ends those benefits once your maximum is reached. Therefore if you have Plan 1, you would only have to pay the amount that the plan would have paid had you had money remaining, whereas with plan 2, you are charged our full office fee.
Hopefully the above examples helped you to visualize the calculations that go in to determining what your plan pays and doesn't pay for certain procedures. As well, these determinations are specific to each plan and we, as the provider, do not have any say in what is paid and what is not since those details are contracted specifically between the plan subscriber and the dental plan. It should also have illuminated that each insurance company, and each plan within it, can be very different which makes it very hard to compare them.
Next week we will wrap up with a little run down of what we do on your behalf to ensure you receive your maximum benefits.