In our last blog post, we covered an overview of dental benefits from the differences between HMO and PPO as well as what typical PPO plans cover. In this post, I would like to cover some routine terminology that the different carriers use as these terms are important to understanding dental benefits. By understanding these different terms that are used, subscribers can better utilize their policy to make sure they are getting the best bang for their buck. I would like to cover “in-network” vs “out-of-network,” pre-authorization, and coverage details.
One of the most common questions that we receive from new patients is “do you take insurance?” and this is understandable as most people want to know what a visit to the dentist will cost. The answer to the question depends a lot on the insurance. If the insurance is an HMO, generally it will only cover any treatment done by a dentist that has signed a contract with the dental carrier. If it is a PPO, it will depend on the policy itself. Most PPO plans allow the subscriber to see a dentist of his or her choosing and have out-of-network benefits, but some may severely restrict which dentists are covered.
If a dentist is out-of-network, the dentist will have more freedom in choosing the best options for the patient and can work more with the patient for needed treatment. If a dentist is in-network, the dentist is more restricted for what treatment can be offered but the cost per procedure will be lower as it is dictated by the dental carrier.
The next common term is pre-authorization. A pre-authorization is a letter sent to the dental carrier that tells the carrier what treatment a dentist is planning to do for a patient. After receiving a pre-authorization, it will take between 1 week to 1 month for the carrier to respond, and the carrier will then tell the patient and the dentist what the carrier thinks it will pay for the treatment. I use the word “thinks” because the carrier will not say that the benefit is promised and about 10 percent of the time, the company pays less than it originally pre-authorized. Unfortunately, the carrier will never be bound to a pre-authorization; however, it can be useful when trying to get an estimate for benefits. Also in our experience, some carriers honor their pre-authorization better than others, and our insurance specialist knows which companies do what.
The last important term that I want to cover is “coverage details.” Each insurance plan has different coverage details. In the last blog, I explained how coverage details are usually broken into preventative, minor, and major, and the company pays at a different rate for each. The preventative treatment is mostly standard across all carriers as it covers x-rays, exams, and regular dental prophylaxis. Much of the variation among plans is what it considers minor and major dental work as well as what major dental work is covered. Most plans consider fillings to be minor work as well as routine oral surgery. On the flip side, most plans consider crowns and dentures to be major work. The two areas where plans diverge is on is complex oral surgery and periodontal treatment as some plans consider these minor and others consider it major. The other common one is implants. Some insurances consider it major whereas others do not cover implants at all.
I hope that this explanation of common dental benefit terms has been useful as most patients do not understand these distinctions. We find many patients think that they cannot use their benefits at out of network offices, that pre-authorizations are definitive treatment amounts, and that their benefits cover everything at the same rate. If you do have questions about how your benefits works or how these different things may affect your dental care, please call us at 504-392-5104 to set up a consultation so that our insurance specialist can help you.