Affording Great Dental Care

DMO coverage is the least expensive coverage that can be bought by you or your employer. Clinics that sign up for these plans get paid a set monthly amount (called capitation) for every patient that signs up. While the premiums may be $20-40 per month, the capitation amount is usually $7-10 per month with the difference going to the insurance carrier. The dental offices sign a contract that they accept the capitation payment and, in turn, waive their fees for basic services and drastically cut their fees for everything else. Because of this, they do not get paid to see you for preventive or basic services and can only charge you if they find more advanced problems. More correctly, they get paid NOT to see you for basic services because if you actually go, their cost to treat you is higher than the capitation payments. This is why we don’t participate. Let your employer know that a PPO or traditional plan is only between 5 and 15 cents more per day and you want to go to a doctor that you choose.

You may pay your bill by mail with a check or money order or, in person. We also accept Mastercard, Visa, Discover and Amex and you are welcome to pay by telephone or by using our patient internet portal. Lastly, if you have a Carecredit, Chase Credit or similar, you may authorize payment by telephone as well.

It is standard practice for a store to bill a customer the day that they buy something. In the same way, our system calculates the number of days your balance is outstanding from the day we performed the treatment, not from when your insurance company makes their determination. If your carrier has delayed their decision by 60 or 90 days, your account balance may show as delinquent when the claim is closed. We apologize for any inconvenience this may cause.

We process credits every 2-3 weeks for accounts where all outstanding claims have been closed. Unless you specify otherwise, we will promptly send you a refund check for the amount that was overpaid.

An EOB stands for “Estimate Of Benefits” and is a statement from insurance company which is generated whenever a claim or pre-estimate is filed on your behalf. Your member booklet, human resources department or your insurance carrier can better explain how to read your EOB as they are all different. In general, it will show you the submitted amount, the insurance downgrades (if any), the percentage of coverage and your financial responsibility. Downgrades or exclusions will usually be coded with a letter or number. A key can be found somewhere in the EOB package which details the reasons for those exclusions. Please remember that you will recieve your EOB up to 3 weeks before we will.

The financial obligation for your dental treatment is yours. The insurance company is responsible to you, and not to our office. We will assist you in any way that we can, but please know that we do not work for any insurance company and therefore cannot guarantee their payment. Once your carrier has paid the claim, any difference will be due upon receipt of our statement. If, for any reason, we have not received your insurance carrier’s payment within 90 days after submitting the claim, the remaining balance will be due and payable by you. Balances over 90 days old are subject to 18% APR.

There are a few times that your carrier may make a mistake with your claim (not many). Generally, claims are automated and electronic. Your carrier’s computers simply apply the rules that you have paid for with your plan and pay accordingly. If the service is not covered by your plan, it will likely not be paid regardless of how earnestly you believe it should. Some claims for more complex procedures are hand reviewed. Despite what you might think, they are not reviewed by a doctor the first time in most cases, just a data entry clerk. In these cases, if you request that the company re-review your claim with a consultant, they may reopen the claim for you. Usually they will then require more information. Make sure that you keep a record of all correspondance and make a list of what you will need. We will be happy to send you the information you need to refile your claim. If you get any additional payment sent on your behalf, we will credit your account appropriately and refund any excess amount.

• Although we do maintain computerized histories of payment by a given company, they change often. Insurance companies are not required to notify us of these changes so it is often impossible to give you a guaranteed quote at the time of service. That is why we stress that our treatment plans can only estimate coverage. Most insurance plans base benefits on a schedule of fees (UCR) arbitrarily developed by the insurance companies themselves and not what it actually may cost to complete your work. Insurance companies are not required to share these fee schedules. For this reason, you may receive a lower percentage than the reimbursement level indicated in your dental plan. For example, if your plan states that it will pay 80% of the cost of a specific treatment, it means 80% of the fee arbitrarily determined by the insurance company and not the actual fee charged by our office. Any quality private practice will bill more than insurance UCR on the majority of procedures.
• There may be a deductible (individual or family) which must be satisfied before insurance will pay for a given procedure.
• Since dental insurance is only meant to assist you, there is usually a calendar year maximum. Your insurance will not pay more than this amount in any given year. If you have seen a specialist or another dentist for care, you probably have used some of your annual benefits. Insurance companies do not notify us of changes like this, they only notify you. It is your responsibility to let us know how much is left in these situations so that we can correctly estimate your insurance.
• Your insurance company uses terms and restrictions like ‘alternate benefits’ or ‘preexisting conditions’ to exclude or downgrade procedures to cheaper substitutes. A common situation is when a carrier will only pay for a silver filling or gold crown. This does not mean that you can not have a tooth-colored alternative. It only means that you will be responsible for the small difference in fees. There are also frequency limits, missing tooth clauses and outright exclusions. It is not possible for us to determine these restrictions for every insurance possibility. Simply put, there are times that your insurance contract will not cover the quality of care you need and deserve.