We understand insurance can be confusing, please discuss any questions/concerns with us. We are happy to help!
Please keep in mind that you are ultimately responsible for payment on your account if your insurance does not pay a claim. Insurance is a contract between only you and the insurance company, not our office. We file dental insurance as a courtesy to our patients. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of fees for treatment and at no time guarantee what your insurance will or will not do with each claim. We cannot be responsible for the accuracy of any insurance information that the insurance company representative has provided to us. It is your responsibility to be familiar and understand your insurance policy and terms. You are responsible for payment of any balance due not paid by your insurance company, including any unpaid deductible amounts or if your plan only allows one fluoride application per year, etc.
Your employer has determined the amount of coverage according to the contract set up with the insurance company. The less paid for the insurance by your employer, the less coverage you will receive.
For example, let’s assume the fee for a service is $100.00. Your insurance benefit states it covers 100% of this service. If you have in-network insurance, the insurance company and the doctor have negotiated a rate of $75.00 for this service. Therefore, the insurance company will pay $75.00 of the $100.00 fee and the doctor will write-off $25.00. Your out-of-pocket will be $0.00 and as a result the insurance has covered 100% of this service. If you have out-of-network insurance, the insurance company and the doctor have not negotiated a rate for this service. Your insurance benefit states it covers 100% of this fee, however, you may still have a co-pay. Why? For the $100.00 fee, the insurance company will pay what it believes is the usual, customary, and reasonable (UCR) fee. Therefore, if the insurance company pays $75.00, instead of writing-off the remaining $25.00 of the $100.00 fee, the office will bill you the $25.00.
Please note: Despite being out-of-network, your insurance may still cover 100% of the fee with no co-pay for you. Some insurance plans provide just as great out-of-network benefits as in-network benefits and it may not make a difference for you to go to an out-of-network provider. For example, in the example above, an out-of-network insurance plan may pay the full $100.00 fee for the service. To find out more information regarding your specific insurance benefits, please call our office at (908) 340-4848.
For example, let’s assume the fee for service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary (UCR) fee, we can figure out what benefits will be paid. First a deductible (paid by you), on average $50, is subtracted, leaving $100.00. The plan then pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. Out of a $150.00 fee they will pay an estimated $80.00 leaving a remaining portion of $70.00 (to be paid by the patient). Of course, if the UCR is less than $150.00 or your plan pays only 50%, then the insurance benefits will also be significantly less.
Please keep in mind that you are ultimately responsible for payment on your account. If your insurance does not pay the claim, you are responsible for the outstanding balance. Insurance is a contract between you and the insurance company, not our office.