Insurance 101

FACT 1:  No dental insurance plan is pay-all. Unlike medical insurances, which often pays for a large portion of expenses after deductible and/or co-payment, dental insurance is only meant to be an aid.  99.9% of the plans have an annual maximum and/or deductible.

FACT 2:  Treatment quotes are purely ESTIMATES and not a guarantee of payment from your insurance. Any underpayment is patient’s responsibility. Doctors do not treatment plan based on what insurance covers but what is best for the patient.  Payment is due at time of service. If you have insurance, you will pay an ESTIMATED COPAY at time of service. PAYMENT is NOT FINAL until insurance pays for claim.

FACT 3:  Many insurance companies state they pay 80%-100%. In spite of what is stated, most plans cover about 40-60% of the average fee.  Some plans pay more -some pay less. Ultimately, the amount paid by insurance is determined by how much your employer paid for the plan and how much profits insurance want to gain. The less they pay out, the higher their profits!

FACT 4: Insurance companies will often “downgrade” or apply an “alternate benefit” to a procedure in order to pay less. A very common example is when an insurance company will only pay a composite (tooth-colored) filling at the rate of a silver (amalgam) filling. Most dentists haven’t done an amalgam filling since graduating from dental school!!  We want to provide you the best care, while insurance only watch out for payout ratios!!

FACT 5:  Did you know that dental practices on the East Coast require that patients pay for services in full at the time of service and get reimbursed by their dental plan after they submit claim forms themselves?  Our office, on the other hand, is happy to submit claims for you as a value-added service and provide you an ESTIMATE.  However, you are responsible to let us know the following information to get claims paid faster and find out exclusions from insurances:

  • Accurate insurance information (Name on policy, member ID or social security number, date of birth and any other insurance coverage)
  • Work done outside our office so annual maximums can be calculated accurately
  • Change in insurance (termination, policy/benefit change, etc.)
  • Any dual insurance (Insurance always require billers to send to primary insurance before sending to 2nd  insurance)
  • Any waiting period for treatment
  • Any missing tooth clause (if tooth was extracted before current insurance being effective, current insurance will NOT cover treatment)
  • Prior history on fillings, crowns, bridges (Most insurance have frequency limitations for how often fillings, crowns, bridges etc can be replaced).
  • Frequency limitations for how often exams, cleanings, xrays, fluoride are covered (we would be happy to look this up for you if you ask).


FACT 6:  X-rays are required for proper diagnosis.  All new patients are suggested to get a full set of X-rays and photos so that our Doctors can properly perform an examination.  We recommend that existing patients renew xrays at least 1 per year. Lastly, xrays and photos are often required to get claims paid.  If you do not want any xrays, please sign a waiver, however, we cannot guarantee claims will get paid for treatments. Our digital xrays emit very little to zero radiation compared to many other things we do on a daily basis such as TV, phones, and computers.