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I paid my copay….why do I still have a balance?

Let’s face it….nobody likes to receive a bill in the mail. If you’ve recently had dental treatment and you’ve received a bill in the mail for an outstanding balance, there may be a few reasons why this is the case.

1.  Insurance companies often downgrade procedure codes for a lesser quality product. The most common example of this practice occurs with white fillings vs. amalgam (silver) fillings. White fillings require more time and expertise to place and use more costly materials, therefore they command a higher fee than amalgam fillings. However, most insurance companies will only pay benefits based on the cost of a silver filling and not a white one, leaving the patient to pay the difference in cost between the two. This is called an “alternate benefit” clause. Whenever an alternate, less expensive procedure can be substituted to achieve a similar clinical outcome, the insurance company will base their payments on that less costly procedure. The downside to these less costly procedures is that they are usually much less esthetic, or offer a lesser quality of life.  Other examples where the alternate benefit clause usually applies are in the substitution of unsightly metal crowns for porcelain crowns, and removable partial dentures instead of dental implants.

2.  Your insurance may have changed since your last visit. Insurance companies’ fee schedules and benefit rules change periodically. Although we make every effort to gather as much information as possible about your insurance coverage, sometimes we are not aware of changes until after your insurance claim has been filed. This can result in a change to your estimated copay, and an unpaid leftover balance.

3.  Your insurance policy expired. Sometimes the information we receive about your insurance eligibility is not accurate. If you have recently left your job your insurance policy may have been cancelled by your employer without your knowledge. Or, covered dependents may have reached an age where they are no longer covered for certain benefits. While much more rare than the above scenarios, this is occurring more frequently now with the advent of Obamacare. Many patients will mistakenly assume that their Obamacare medical policies include dental coverage, when in reality they don’t.

As a courtesy to our patients we make every attempt to verify your insurance benefits prior to any treatment and process insurance claims accurately. If your insurance coverage has changed, please let us know prior to receiving any treatment. And most importantly, if you have any questions about your insurance coverage please do not hesitate to ask – we are more than willing to help!