Answer: While we have no contracts with any insurance companies, we work with all insurance companies that allow you the freedom to select your own dentists. The best way to optimize your insurance benefits is to partner with our office professionals who understand the ins and outs of the dental insurance business. Most all insurance companies will pay for basic services, for any dental office, including ours. Since we do not contract with an insurance company, we have no power over what they pay or won’t pay.
Question:“Do you submit the claims for insurance payments?”
Answer: We have found that the best way to maximize the amount of benefit for you, the patient, is for you to submit the claim yourself. If you need to submit any protests, we will help you to write them, and we will assist you in every way we can; but we find that you’re the one that’s going to have to take action, because you’re the only one they listen to. And you’ll get your claim paid if you can make enough noise.
Question:“Are your fees considered to be “Usual, Customary and Reasonable” for the area in which you’re located?”
Answer: The “UCR,” or “Usual, Customary and Reasonable” fee rationale is fictitious. The insurance companies make them up. There have been several successful lawsuits brought against insurance companies that engaged in this practice. Insurance companies cannot prove in court what UCR’s are, because they don’t exist.
Question:“What will my insurance company pay?”
Answer: Every insurance company is different, and even within an insurance company, there are different plans and policies. We don’t know what your employer has negotiated with your insurance carrier, so the best way to find this out would be for you to call them. They don’t listen to us, and they don’t respond to us, but if you call and ask the insurance company what they pay on their different services, they should give you an up-to-date fee schedule.
The better insurance companies will pay up to 100 percent of basic and preventative services. Normally, they will pay 80 percent to 100 percent of our fees, because they are reasonable for the dentists in Orange County.
Question:“What kind of insurance do you take?”
Answer: Almost every insurance company that does not have a “closed panel” of providers will cover the basic services at our office. And almost every insurance company nowadays will pay for out-of-network providers.
Question:“Do you pre-authorize dental treatment?”
Answer: With some insurance companies, pre-authorization is a requirement. With many of the better companies, it is NOT a requirement, because they know that many services need to be taken care of right away, and when it comes to emergency services, almost all of them do not require a pre-authorization.
It depends upon a person’s needs, and the individual rules of that insurance carrier. But even so, if service is necessary because of pain, we can’t wait for a pre-authorization. The carriers are required to cover that.
Question:“Do you take insurance as payment in full?”
Answer: While many offices do take insurance as payment in full, in the State of California, this is illegal. The state has investigators who check out various offices, and many dentists lose their licenses for engaging in this practice. They can possibly even go to jail if they do this on a wholesale basis. And while you may find some who will do it, they may be risking their careers.
You may be able to find some unethical dentists who will do this. Many of them will over-bill, pad the bill, and add extra charges to that insurance claim at the same time, but you’re putting yourself and the dental office at risk. You would be complicit in insurance fraud, a willing participant in committing a crime. If you and the other dental office are willing to take that risk, you may be able to find an unethical dentist who is willing to cooperate with you in committing insurance fraud.
Question:“Can you backdate or predate an insurance claim to get me coverage?”
Answer: If any treatment or exam was started before the date in question, it is more than acceptable to do that, but anything else is still insurance fraud. And while many dentists and many patients are willing to take the risk of committing insurance fraud, and potentially committing a crime, we’re not willing to do that.
Question:“You frequently give patient discounts. Should insurance claims be filed for the full amount?”
Answer: This is a gray area, because some insurance carriers interpret a discount as a lowering of fees. So, if a service is performed that normally costs $100, and a $20 discount is applied to that, then the correct fee submitted to the insurance company should be $80.
If the insurance company pays fifty percent on a claim, then the correct payout would be $40. If, after receiving the discount, a claim was submitted for the full-price fee of $100, and the insurance company then paid the patient $50, that would, technically, be insurance fraud, because an incorrect fee was submitted to the insurance company.
Question:“What about cash discounts?”
Answer: If you pay cash up front in order to qualify for a cash discount, (just as some merchants do for people who pay with cash rather than credit cards), that practice has (so far) been held as being acceptable. But we have to be very careful, and make sure we designate it correctly—it is not a discounted fee, but rather a discount for paying cash, eliminating the need for us to pay the credit card handling fees.
Question: “What if I have Dual Insurance coverage?”
Answer: Most, but not necessarily all of the time with dual insurance, there are specific ways the insurance company has a written policy on how they’re going to handle it. The way it SHOULD work, and the way most of it works, is that 100 percent of the fee gets paid because the primary carrier pays the majority, then the secondary carrier makes up whatever balance there may be.
However, sometimes insurance companies put in provisions stating that they will only pay up to a certain percentage of a claim, regardless of dual coverage. If, for example, only 50 percent of a claim is eligible to be paid, then if the first insurer pays 40 percent on the claim, the second one is only going to pay 10 percent. If the first insurer pays 50 percent, then the second one will pay nothing.
Question:“What if I have an HRA or an HSA?”
Answer: There are certain government regulations that have been passed several years ago regarding HRA--Health Reimbursement Accounts, and HSA—Health Savings Accounts. Every company has certain rules and provisions that allow the patient to utilize their services, but that’s an employer-based operation. It’s not an insurance company; it’s a self-funded division of the employer’s.
It’s almost like an account that can be tapped into to pay for health or dental services. Every employer sets their own rules, so patients need to check with their employer representative and find out their rules and provisions, and then get back to us.