Why Doesn't My Dentist Know How Much My Insurance Will Cover?

Picture this scenario: You go to the dentist because your tooth is throbbing and it has been keeping you up all night.

The dentist says you need a root canal and a crown.

Now what?

When you find out a root canal costs $1400...

When you find out a root canal costs $1400...

Most patients will have questions along the lines of:

Will my insurance cover this? How much do I have to pay?

This frustration is compounded by the lack of information from dental insurance companies.

Dental practices do not have the exact dollar amount that your insurance will cover. Insurance companies only provide percentages to dental practices. The typical range of the majority of procedures is 100-50%. As a result, dental practices will give you the co-pay as:

Fee for XYZ Procedure * .80 (80%) = Your co-pay

Unfortunately, insurance companies do not calculate coverage this way.

Every insurance company has different, wide-ranging dental products that they offer. As a result, almost every policy will have it's own unique 'Allowed Amount' - which they determine upon receiving the claim.

"So insurance companies tell you the 'Allowed Amount'?"

No. Insurance companies do not share this 'Allowed Amount' with the patient or the dental office leaving everyone a little bit confused.

There is a way around this cloud of mystery. It is called a Pre-Estimate or Pre-Authorization. This helps you get a better idea of what insurance will or will not pay. The dental office will have to submit these and it'll take roughly 3 weeks to hear back from them.

The most common misconception with Pre-Authorizations is that patients believe insurance will honor the amount they were quoted. In some cases the actual claim for the procedures will be the same as the Pre-Authorizations. Half the time some things will change. Either the Maximum was met. Or they recommend a different type of treatment than what was performed.

The lesson: If you walk into a dental office and they say you need a crown or a root canal, they will give you an estimated co-pay BUT it is not a guarantee of payment.


 

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