Naperville Family Dentist

Joseph A. Haselhorst D.D.S

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Dental Insurance

Our office has a policy of doing everything possible to insure our patients receive the maximum benefits possible from their primary insurance company (we no longer submit secondary insurance claims). With the number of patients and the myriad of plans we deal with on a daily basis, we must rely on you to know the basics of your plan coverage and notify us promptly of any changes in your coverage. Dental insurance is becoming increasingly more complex each year. It has become so complex that at most dental conferences, dental insurance seminars are common and last anywhere from 4 to 8 hours. The constantly changing procedure codes, the number and types of plans / policies and the disobliging attitude toward dental offices by certain insurance companies all make settling claims more time consuming and difficult (there have been class action lawsuit filed based on insurance companies handling of claims).

A common question we get is: Do you accept my insurance company or policy? We file claims with all insurance companies and policies, but your insurance company may restrict benefits. I know of no dental office that maintains a list of insurance companies they will not work with or insurance policies they do not accept. The insurance companies keep lists of dentists that have signed contracts with them agreeing not to disclose certain information to patients. Our office has been unable to find any of these contracts which do not seriously infringe on the patient / doctor relationship (i.e. restrict what treatment options maybe discussed with the patient). Dr. Haselhorst is unwilling to sign any contract allowing insurance companies to control your treatment. These contracts are associated with two of the three types of dental plans common today and only one limits coverage to contracted dentists. The three types of plans are Indemnity, Preferred Provider Organization (PPO) and Dental Maintenance Organizations (DMO).

Indemnity plans are the original and oldest type of dental insurance. These policies do not require dentists to sign a contract to participate or restrict benefit based on participation. Dental procedures are grouped into classes and benefits are a percentage of the fee charged, based on the class of the procedure (i.e. preventive, restorative, major). There is usually an individual and family deductible, which applies to certain dental procedures, and must be meet before any benefit will be paid. Each individual covered under the plan has an annual maximum (usually between $1000 and $2500). The plan may cover orthodontics, usually only for adolescent dependent children. These plans usually include riders (clauses) excluding certain treatments from consideration for benefits (i.e. cosmetic dental procedures) and restricting the frequency of other treatments (i.e. dental cleanings once in 6 months). Since these riders vary so much from plan to plan we have to rely on our patient to make us aware of these restrictions. You should at least know and be able to tell us your deductibles and maximums at your first visit.

Preferred Provider Organizations (PPO) were created by the insurance industry when the dental equivalent of the HMO, the DMO, failed to succeed. This type of plan has individual maximums, deductibles and riders, like Indemnity plans, but provides benefits based on a Fee Schedule (for more about fees schedules click here) instead of a percentage of the dentist’s fee. There are two lists associated with this type of plan, a Preferred Provider List and a Schedule of Fees. The dentists on the Preferred Provider List have all signed contracts with the insurance company agreeing to a set of treatment terms stated in these contracts. You are not required to go to a dentist on the Preferred Provider List; the benefits provided are the amounts stated in the fee schedule, regardless of the dentist or their fee for a procedure. Only dentists that have signed a contract have access to the Fee Schedule for a plan, so only they know how much of their fee will be covered by your policy. Not even the insurance company can accurately answer this question until a claim is filed. Remember these contract dentists are contractually obligated to the insurance company, not you (i.e. they work for the insurance company not you). Again, you should at least know and be able to tell us your deductibles and maximums at your first visit.

Dental Maintenance Organizations (DMOs) are the dental equivalent of Health Maintenance Organizations (HMOs). When you sign up for one of these plans you will be given a list of dentists to choose from and you must place their name on your enrollment form. You do not have any coverage if you do not choose a dentist at the time of enrollment and you may only change dentists during your open season. The dentists on this list have all signed contracts with the insurance company agreeing to a set of treatment terms stated in these contracts. There are no claims to file, since your dentist is responsible for managing your dental treatment. The insurance company sends a check each month for a set amount per enrolled patient to your chosen dentist. Most of the dentists on the list are members of a large clinics or just starting their practice. For the dentist just getting started, this guaranteed monthly income is essential. For the clinic member it supplements the income from their private practice. Since any dentist in the clinic can see you, these dentists can take turns working at the clinic and seeing patients. This type of dental plan works well for treating problems when they occur, since the dentist or clinic will likely receive months if not years of payments before you go to them for care. Regular preventative care costs more then the amount paid by the insurance company to “manage” your care, so preventative care is generally not practiced. Prevention means annual or bi-annual checkups to treat your dental needs before they become problems. Dental healthcare, unlike medical healthcare, is base on prevention not treating the problems. This is the reason that DMO plans do not work well for dental healthcare and are not very common. Because of lawsuits filed by patient under DMO plans, most of these plans now have a special appeals process to provide care for serious health or life threatening conditions (i.e. cancer).

When an insurance claim is settled you will receive an Explanation Of Benefits (EOB) from your insurance company, which explains your claim settlement. This is an important document and should be placed in safekeeping. Insurance companies will not provide any additional copies should the original be lost. You need to learn to understand this document. It will help you to better understand you insurance coverage and how to maximize your benefits. On this EOB the dental treatments or procedures will be described by a procedure code. These 4 digit code numbers (ADA Codes) are unique to dentistry and uniquely describe each procedure performed during your dental visit. These codes are the basis of Indemnity policy classifications and PPO fee schedule listings. You will need to know these codes when discussing your EOB with the insurance company or our office. A term that use to be in common use by insurance companies on these EOBs was “Reasonable and Customary” (also called URC, Usual, Reasonable and Customary). This term was actually defined differently depending on the insurance policy. In late 2001 the American Dental Association filed a class action lawsuit against an insurance company on several grounds one of which was it ambiguous use to the term “Usual, Reasonable and Customary”. This case was settled in late 2003 and as a result you will no longer find the term used by insurance companies when settling claims. For more help on understanding your EOB click here.

Another source of confusion is the fact that several Insurance Companies are associated with or are owned by other insurance companies. We get calls from patient all the time telling us we sent their claim to the wrong insurance company. The following are example:
Aetna is also MetLife and Prudential
Cigna is also Connecticut General and Equicor
Trustmark is also Coresource
Guardian is also First commonwealth

It is an unfortunate fact that much of the confusion regarding insurance policies and claim settlements are the direct result of insurance company philosophy. Some of these have changed over the years, but usually only as the result of losing some lawsuit. Some insurance companies rely on making the claims process as difficult and confusing as possible to reduce claim settlements and deny benefits to policyholders. The use of 'coordination of benefits' on secondary insurance claims is a good example of this. The insurance companies are usually more helpful when dealing with the policyholder, so we will from time to time ask our patient to contact their insurance company to solve a problem. It is not unusual for an insurance company to delay claim settlement waiting for addition information from us or the policyholder, please respond quickly to any request from your insurance company. Lastly, some insurance companies automatically denied claims for certain covered dental procedures as part of their claims processing policy. These denials can always be appealed and usually benefits will be awarded once the company realizes that the doctor and policyholder are determined in challenging such denials.