Insurance provider plans are constantly changing these days. Please contact the offices of Robin Dale Lobato, DDS, PC directly for details about your dental insurance plan. Learn which dental insurance plans Dr. Lobato is contracted for as an “In-Network” provider here.
Insurance Billing and Financial Policy
We will bill your primary dental insurance company as a courtesy, however, your account is ultimately your responsibility regardless of any insurance or quotes. Should your insurance take more than 45 days to process payment, your account balance is due directly from you or late fees and/or administrative fees apply. Should you need assistance in appealing your insurance claim, more than one insurance appeal will result in administrative fees due directly by you. We expect all of our patients to be active in assisting our office with any insurance difficulties and appealed claims requests. Please contact our office for a copy of our financial policy.
Your dental insurance plan is designed to assist in paying a portion of the costs associated with dental care that you insurance company deems as ‘medically or dentally necessary’ as the individual company deems as ‘essential in maintaining normal health’. Dental policy selection determines which services will be covered and which will not as well as amount of payment the policy or company deems as ‘usual reasonable, and customary’ based on insurance terms. Most insurance companies do not provide benefits for treatment the policy deems as ‘discretionary or cosmetic’. It is important to note that even a pretreatment estimate or ‘authorization’ does not guarantee benefit. Insurance companies only approve benefit levels after a actual claim of services rendered is received. Only a licensed dentist can provide a diagnosis for recommended or necessary treatment. Insurance companies are NOT permitted to diagnose or alter treatment necessary, but often provide an alternative (lesser) benefit for payment based on policy provisions. The most common types of dental insurance plans are Preferred (or “Participating”) Provider Organizations (PPO), Dental Health Maintenance Organizations (DHMO), and Dental Discount Plans. Dental insurance can be very perplexing because every insurance plan handles things differently. Dental insurance plans are a contract between you and your insurance provider often selected by and coordinated with an employer. It is important that you read your insurance policy, or talk to your human resources benefit coordinator, so you can understand you individual policy and limitations.
Decreasing Dental Benefits
Las Vegas dentists have found that annual dental insurance maximums have not kept up with inflation. Nearly 40 years ago a typical annual maximum benefit was $1,000. Several years later, most dental coverage still only offers a $1000 maximum. To keep up with other increases in services, dental insurance would have had to increase to more than $4000 of benefits today.
Cost vs. Benefit
We are finding that most Las Vegas employers and patients are selecting plans with higher deductibles lower insurance reimbursement, more limits on annual maximum benefits, and more exclusions to their policies in an effort to maintain or lower premiums. Dental Insurance is considered a ‘rider’ to most medical plans, similar to vision. If you wish to have a dental carrier to provide higher than average coverage, your employer may offer an option to you to pay a larger premium than ‘regular’ dental plan that is offered. Las Vegas dentists are finding more and more plans exclude treatments that the insurance company regards as ‘discretionary or elective’ rather than what the doctor prescribes as ‘necessary dental care’. Some examples of limitations and exclusions from most dental plans include: dental implants, porcelain veneers, tooth colored fillings, bonding, periodontal care and periodontal necessary medications, teeth whitening, dental sealants, and fluoride treatments. Insurance rarely pays 100% of care, and when insurance includes or advertises ‘free’ services, it’s because your premium covers these costs NOT because they are ‘free’. Generally, you get what you pay for: the greater the dental benefit, the higher the dental premium.
Quality vs. Value
For the most part, a dental policy will cover only the least expensive dental procedures and materials, and is referred to by insurance companies as an ‘alternate benefit’ or a ‘downgrade’. An example of a typical downgrade is most often found for fillings and crowns. As a Las Vegas dentist, Dr. Lobato does not downgrade to mercury fillings, instead he offers high quality white composite fillings. The highest quality of care and materials is the best value for your dental health.
Most insurance companies have their own fee schedule, and they pay the percentage stated in your policy according to limitations. We will do our best to estimate what your plan might pay for treatment, and we are accurate most of the time, but there is no guarantee of insurance benefit. Dr. Lobato’s representatives can assist you in understanding some of the generic terms used by your insurance company, but since there are thousands of policies and each one is different; our office cannot be held responsible for knowing or quoting the details of your plan to an exact amount.
Most plans reduce benefits though deductibles and co-payments. Whatever portion of the bill is not paid by insurance is your responsibility. Las Vegas dentist have no control over insurance payments and benefits are determined at the time of service. Your insurance company is required to provide you with a copy of an explanation of benefits (EOB) for all services billed. We file claims for you as a courtesy, but we have no control over your insurance contract or their payments.
Table of Allowances
This payment method lists the treatments the insurance plan pays for, and the fixed amount allowed for each treatment.
Usual, Customary and Reasonable Fees (UCR)
This payment method sets a maximum fee amount allowed for treatment, and then pays 50%-80% of the set fee the insurance deems as usual for the zip code of the provider. You pay 20%-50% of that fee, plus any differences the insurance deems as an ‘upgrade’.