Dental Insurance Information, Zoom Portland Oregon, Sedation dentistry, Mercury-free


		patient resources ::: dental insurance benefits Understanding your dental insurance is the key to maximizing the benefits that it offers you. Unfortunately, for many, dental insurance can be confusing. And to make matters worse, every insurance carrier follows different rules and provides varying levels of care. Dental insurance plans are a negotiated contract between you or your employer and an insurance company. They range from fully reimbursed coverage of any care level you chose and complete freedom of care provider choice to no provider choice and discouragement of any care. If you want to be able to choose your dentist and the quality of care you receive you'll want to be very careful about which insurance plan you choose. There are several categories of dental insurance to choose from. Click on the links below to determine which type is right for you: Direct Reimbursement Preferred Provider (PPO) UCR or Indemnity Program Health Maintenance Organizations (HMO) or Capitation Plan Direct Reimbursement In Direct Reimbursement programs, your employer reimburses you directly for part or all your dental treatment. Usually all types of treatment are covered and you can see any dentist you choose. In addition, you are free to choose the quality of care with which you are most comfortable. The American Dental Association views this as the best employer-patient insurance plan available today. About 95% of the monies spent on a Direct Reimbursement program goes to actual patient care. Since an insurance company is in business to make money, they make more when they sell a plan that provides less benefit to the patient and more to the administrator of the program. Unfortunately because of this, Direct Reimbursement Programs are often the last plans employers are told about. If you would like to learn more about Direct Reimbursement programs, contact the American Dental Association (ADA). Back to Top Preferred Provider Organizations (PPO) In Preferred Provider Organization programs you must choose from a specific group of dentists who have agreed to provide minimal care for the least cost. Participating dentists have agreed to discount their fees so they can be a part of the program, and must often limit treatment options. Treatment choices are usually limited to the least expensive option regardless of desires of the patient for higher quality care. Patients are funneled or referred to these participating dentists by the insurance network. If the patient chooses to see a dentist who is not designated as a "preferred provider," that patient may be required to pay a greater share of the fee-for-service. Only about 81% of the monies spent on a PPO program goes to actual patient care. The remaining 19% goes to the insurance company. In a PPO, patients are limited in the choice of doctor and the quality of care they can receive. The largest PPO in Oregon is Oregon Dental Service (ODS). Bridgeview Dental Associates files fees approved by ODS, but we do not participate as preferred providers. This means that we participate with ODS as an indemnity or UCR program only (see UCR programs). Unlike other indemnity programs, however, with ODS the UCRs are known and accepted fees. Our commitment to the highest quality dental care keeps us from participating in managed care programs, such as PPOs or HMOs. Back to Top UCR or Indemnity Program Indemnity or UCR plans are the most common insurance programs. The initials UCR stands for Usual, Customary and Reasonable. In these programs you may find a dentist of your choice and the dentist is paid on a traditional "fee for service" basis. Monthly premiums are paid to the insurance company by employers. Indemnity plans often pay for services based on a variety of fee schedules. These plans often have a pre-determined deductible, a dollar amount which varies from plan to plan that the patient must pay before the insurance carrier will begin paying for care. Once the deductible is met, the insurance pays a customary 50% to 80% of the insurance company's UCR fees. Leaving 20% to 50% or more of the total fee to be paid by the patient. Unfortunately, UCR rates are often arbitrarily set by the insurance company and are not representative of local dentists' fees. In fact, it is not unusual for the same insurance company to pay different UCR fees to the same dental office, depending on the plan purchased by different employers. This means insurance companies often have different UCRs for the same geographical area and for the same group of dentists. The American Dental Association considers this dishonest and has taken legal action against the larger insurance carriers. Often insurance carriers set the UCRs far below the area's usual professional fees, so patients may wind up paying more out-of-pocket. These insurance companies send out an "Explanation of Benefits" letter to patients with claim-denial language that states: "The provider has charge excessive and unreasonable fees", when in fact the fees charged are below the average for the geographical area. This is very misleading to patients and the American Dental Association filed several lawsuits in 2002 alleging that insurance carriers have interfered with the dentist-patient relationship, and have attempted to influence patient care. Only about 82% of the monies spent on a UCR program goes to actual patient care. The remaining 18% goes to the insurance company. All UCR programs have limitations and exemptions. This means the contract that you and your employer have with your insurance company almost always covers only lower quality materials and services, which may not be the best treatment choice for you and your family. That is why it is very common for patients to choose dental treatment that their dental insurance won't fully pay for. In addition, all UCR programs have a yearly maximum allowable benefit. Unfortunately, the annual limit of dental insurance benefits hasn't changed in 40 years. Back in 1960, a typical annual coverage maximum was $1,000. Today, 40 years later, the average maximum is still about $1,000, despite inflation and the cost of living increases. To keep up with inflation, that $1,000 in 1960 would of had to increase to about $7,000 today. Dental benefits have remained the same, while the premiums and costs of services have greatly increased. And most insurance plans often exclude new treatments they can label as discretionary; even common treatment such as implants, veneers, white fillings, bonding, build ups and whitening. In many cases, your insurance company wants you to only consider the cheapest dental procedures. But we believe that you should be able to choose the best, most durable dental treatment and materials for you and your family. Most insurance companies not only want providers to limit the choice of procedures offered to patients, but the insurance carriers often refuse to share critical information with providers. This includes specific information regarding payments of dental benefits. In addition, any information shared with providers is disclaimed with a non-guarantee statement. This means that insurance companies reserve the right to mislead providers with false, out-of-date information or change information after sharing it with providers. So it is always best for you to call your insurance carrier to verify your benefits or to inquire about coverage. The team at Bridgeview Dental Associates will be glad to share with you the procedure codes you will need to provide to your insurance company in order for you to estimate your patient portion. Our staff is glad to attempt an estimate for you, but because of misleading tactics of insurance companies those estimates cannot be guaranteed. Other tactics used by UCR plans include delay tactics. The most common delay tactic is refusing to pay for treatment without completely unrelated x-rays. For example, they may refuse to pay for treatment completed on a patients upper right teeth without x-rays of the lower left teeth. These tactics used by insurance companies cause an increase in expenses, resulting in higher cost to the patient. Back to Top Capitation or HMO Capitation plans are another form of managed care. They are also called a Dental Health Maintenance Organization or HMO. Participating dentists are paid a set amount for each person enrolled in the plan, rather than for actual treatment provided and whether they visit the dentist or not. Unfortunately, this type of plan encourages a "significant delay" in treatment, minimal services and the use of lower quality material. In other words, the provider looses money every time you require treatment or need to be seen, although a small co-payment is due at each visit. The best financial situation for participating providers is to delay care or limit treatment options to the least expensive option regardless of desires you may have for higher quality care. And you can only see participating dentists and specialist, regardless of the quality of care you feel you are receiving. If you decide to see a dentist who is not on the HMO list of providers, charges for service will not be covered by the plan. Only about 73% of the monies spent on a HMO program goes to actual patient care. The remaining 27% goes to the insurance company. Back to Top