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Insurance carriers normally calculate their fees (UCR). This is not
a list of what the dentist should be charging, but what the individual
policy or insurance company determines to pay. The insurance companies
determine UCR fees by surveying dentists in a specific area. The doctor’s
fee is considered to be within the UCR range if the fee does not exceed
60% of the dentists surveyed. Many other variables exist in how UCR
fees are determined and insurance companies are usually several years
behind in upgrading their fees. Their fee schedules are therefore typically
lower than many individual dentists in the area.
How is the benefit package determined?
The insurance carriers make payment equal to a percentage of the UCR
fees. This amount has been NEGOTIATED by the EMPLOYER purchasing the
plan and depends entirely upon the amount EMPLOYERS are willing to
pay toward insurance premiums. Patients are responsible not only for
the remaining percentage, but also for the difference between the UCR
fee schedule and the doctor’s fee schedule, as well as a possible
annual deductible. If you are aware of the UCR fee schedule, it will
help avoid confusion. The insurance company will not send a list of
their UCR fee schedule to our office. You may be able to obtain this
information from your employer’s personnel department
Can the doctor waive the co-payment?
Doctors who waive the co-payments run the risk of being charged with
fraud resulting in fines, suspension of license, or other disciplinary
measures. This is not a legal practice.
Let’s discuss the responsibility of the dental office:
The dental office is a third party, outside the agreement between
you and your insurance carrier. We will, as a courtesy to our patients,
complete and file the insurance forms with the insurance companies
and take assignment of benefits (having the insurance carrier make
payment directly to us.) This allows you to pay only your co-payment
at the time of treatment and we will wait for payment from the insurance
company. (We do require full payment for insurance that will assign
benefits only to the patient, i.e. Delta Dental.)
These are the responsibilities of the patient:
The insurance carrier is responsible to patients, and patients are
responsible to the dental office. Therefore, patients are legally responsible
for their entire accounts, not only the estimated patient portion if
any problems arise.
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