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SW Nebraska Dental Center
A Great Dentist

Let’s Talk About Dental Insurance: Volume III

September 26, 2019
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Posted By: Katie Schutte

Let’s Talk About Dental Insurance Series

Volume II:  Let’s talk dental insurance clause and imitations

By Katie Schutte

Welcome to volume III of our mini blog series about all things dental insurance!  Last week we talked about the differences between annual maximum versus deductibles, as well as calendar year versus benefit year.  This week we are focusing on the insurance limitations and clauses or “loopholes” that the insurance company uses to avoid payment of claims.

Let’s Talk Frequency and Age Limitations.

These are the most common limitations when it comes to dental plans.  There normally are frequency limits on all procedures.  The frequency limit is best described as the number of times in which the insurance carrier will pay for a procedure.  Each policy is different, however, cleanings and exams are typically two per calendar year; meaning the patient can only have two exams and two cleanings anytime from January 1 to December 31.  Although, sometimes, cleanings and exams are one every six months; meaning that cleanings and exams have to be spaced six months apart for the insurance policy to pay the claim.

There are also frequency limitations on x-rays, sealants, fluoride placement, etc.   It is important for a patient to monitor when their last visit was and how often they can come in according to the frequency limits on their plan, helping to ensure they are not receiving a cleaning, x-rays, fluoride etc. too early.   For example, if a patient sees us for cleanings in January and July, and would like to be seen prior to January for a cleaning and exam there would not be any insurance benefits available for this appointment. 

Ok, let’s talk age limitations.  Age limitation is described as the age range in which a service will or won’t be covered.  Fluoride and sealants are the codes the most frequently denied due to age limitations.  Typically, for fluoride and sealants, insurance companies will only pay for children with age limitations that can very.  Fluoride varnish is a very beneficial service we provide and we advocate all of our patients to receive it while in our office.  However, it may not be covered by your insurance due to your age. That does not mean you should not get it! Insurance does not always write the policies in your best interest.  It’s best to call your insurance company to make sure that you or your child fit the criteria or you are prepared to pay out of pocket for that service.  Sealants also typically have an age and tooth limitations. 

Let’s Talk Missing Tooth Clauses and Replacement Clauses.

First, the missing tooth clause: if a tooth is lost before the effective date of the insurance policy; the carrier doesn’t bear any responsibility to cover replacing the tooth. Meaning if you lost a tooth before you were on your current policy, they will not cover replacement of this tooth and it then becomes an out of pocket expense.  I suggest having the office send in a pre-determination to see if your policy has this particular clause.  Pre-determinations are not a guarantee of payment, but they can help catch missing tooth clauses.

Replacement clauses are similar to frequency limits.  Dental insurances have set an averaged time frame of how long they feel services should last, without taking into consideration that life happens.  With that being said, insurance companies will only replace fillings, crowns, dentures, etc. after a specified amount of time has passed from the date of the initial treatment.  For example, if a patient needs to have a crown replaced due to breakage or decay, the insurance company will only pay after their specific time period has passed. This time will vary from policy to policy. It is best to talk to your insurance company and keep a record of your dental treatment. 

Our office offers dental warranties on dental treatment such as dentures, crowns, and bridges; because we understand that sometimes dental treatment needs to be replaced before the replacement clause is satisfied.

Let’s Talk Waiting Periods.

Simply put, the insured must wait a specified amount of time to get a procedure done.  Waiting periods are common on self-pay policies (ones not through an employer).  Most of the time waiting periods only apply to dental treatment such as fillings, crowns, gum treatments, etc.  By imposing waiting periods, the insurance company is avoiding paying for preexisting conditions.  

Let’s talk Downgrades.

Dental insurances are so tricky.  They will substitute a lesser fee when they deem treatment “unnecessary”.  For instance, we offer composite (or tooth colored fillings) at our office.  Some dental insurances, deny the “tooth colored” fillings because they will say that the newer, better, more esthetic option is not covered but they will pay the cost for older, cheaper, silver fillings.  The companies downgrade and pay the silver filling fee and the patient is responsible for the difference. 

It is important we stress that as a patient; you should know what the restrictions and limitations are prior to making a decision about dental insurance or getting dental treatment.  At the end of the day, your decision needs to be based upon what is best for your health rather than what your dental insurance will pay.  At our office, we don’t want dental insurance to dictate our patient’s treatment.  We want to do what is in the best interest of our patients; sometimes that means placing fluoride varnish on a patient with a high caries rate.  Will insurance cover it? No.  Is it in the patient’s best interest to prevent decay?  Yes.  A crown breaks after 4 years; it is in the patient’s best interest to get a new crown.  Will the insurance pay for it? No, BUT that does not mean that it isn’t needed. 

Bottom line of this blog post, as an office, we want to help our patients maximize their insurance benefits, however, we also want to do what is in their best interests. Letting insurance dictate our patients treatment is not the goal.  Empowering our patients to understand their policies, prevent confusion and upsets is our goal.  If you have any questions please contact our office at 308-345-2273 or email us at [email protected]  We are happy to help you!  Stay tuned for our next blog of the series!  We are diving into the world of co-shares and providers that are in-network versus out of network.

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