January is typically a month where we get a lot of insurance questions. Most plans are based on a calendar year, and many companies change their insurance carriers every one or two years in order to find the best rates. It can be confusing and difficult to understand, and we are here to help.

Our business staff has an excellent relationship with the many insurance companies used by our patients. Both Cindy and Donna have years and years of experience with helping patients manage their insurance coverage. Here are a few tips they would like to share with you:

Many insurance companies no longer issue identification cards. Instead, they make benefits available online.  It is very important that you come to each appointment with your most up to date benefits in hand.  If you have an ID card, please bring it, along with any benefits booklet or benefits printed from your online source. We need to know your insurance identification number, which is usually different than your social security number. We also need to know your group number, which identifies your particular place of employment amongst the many clients your insurance company serves. Phone numbers, mailing addresses and web addresses of your insurance company are critically important in processing your claims in a timely manner.

Every insurance company (for example, Delta Dental, Anthem, Medical Mutual) has a different plan based on the level of benefits your company is able to purchase. So within a single insurance company there are literally hundreds of plans. Two plans from the same insurance company can be vastly different.  It is based on the coverage your employer purchases.

 The term “reasonable and customary” is a very confusing term. Like any business, an insurance company needs to make a profit. So they figure out how much money they can pay for different procedures and still make a profit from the amount of premiums you and your company pay. Insurance industries pay for the gathering of data from dentists within a geographic area, seeing what procedures are most typically used, and from those numbers, decide how to set their reimbursement levels so they can make a profit.  Often this data gathered from dentists is several years old. Reasonable and Customary means nothing more than how much your insurance company is willing to contribute toward any specific procedure based on the level of premiums you pay.  It often has little to do with the actual cost of a procedure.

Always remember that when your insurance benefits list that procedures are covered at “100%” or “80%” what they are saying is that they will pay 100 or 80% of whatever amount they decide. So if they decide, based on your specific plan,  that they will cover $50 for a cleaning, then when they tell you they pay 100%, they mean they pay 100% of the $50, not the actual cost of the cleaning. Your premiums are based on the assumption that you will use all of your allowable benefits.  Not using the benefits you are paying for is like handing your insurance company a check at the end of the year.  The amount of benefits available to you at any given time is usually readily available online.

Insurance can be very confusing. If you have any questions about your insurance coverage, or your explanation of benefits, please don’t hesitate to give us a call at (330) 725-2242.    Our resident insurance gurus (aka Donna and Cindy) are happy to help!