This document reflects how I treated and regarded dental insurance when I was in practice. It is presented to you objectively and reflects the reasons why many dentists treat insurance the way that they do.
TO MY PATIENTS:
During the past four decades, dental benefits plans have become an integral part of health care planning for many families.
Dental benefit plans are made available to employees or members, through companies, unions, and associations, and may vary considerably from one plan to the next.
The range of benefits depends solely on what the plan purchaser wishes to offer employees or members and spend for this coverage. Some plans may cover as little as 30% or as much as 100% of dental services, with most falling in the 50% to 80% range. Some plans exclude certain types of services, e. g., orthodontics, while other plans will cover a full range of dental services.
Some plans base the amount of the benefit on a chart or schedule of fees arbitrarily developed by third-party payers. These schedules are set arbitrarily and do not reflect current dental fees. Some claim to be based on what is called UCR (usual, customary and reasonable) however they do not disclose at which percentile of this figure or from what year the data they use was collected. For this reason, you may receive a lower percentage of the reimbursement level indicated in your dental plan. For example, if your plan states that it will pay 80% of the cost of dental treatment, it means 80% of the fee as determined by the insurance company, and not the actual fee charged by your dentist.
As the number of patients covered by dental benefits plans has increased, certain assumptions have become evident and I would like to make the principles of how I practiced, as well as the type of service and care I provided my patients, very clear:
My fees are based on the overhead involved in my practice, the treatment plan selected, and the time it takes me to provide you with the necessary dental care. I do not believe it is in either of our best interests for me to compromise my recommended treatment, in order to accommodate a dental plan's maximum benefits that may be considerably less than optimal. Remember the insurance company is not in business to guarantee your health, they are in business to make money for their stockholders.
However, I am more than happy to discuss a treatment plan's advantages and disadvantages with you thereby involving you, not the third-party payer in the decision-making process.
The type of treatment you need and receive from me is based upon my professional judgment, and not on whether you are covered by a dental benefits plan.
As a courtesy to you, my staff will complete the dental portion of the claim form. To expedite processing, make sure that your part of the form is filled out completely and accurately.
If you direct the insurance company to pay its share of the cost directly to my office, you will receive credit for this amount and be billed for the balance. Upon receipt of payment from the third-party, my staff will reconcile the amount and bill, or refund, any difference.
If your dental benefits plan requires a predetermination or prior authorization, I will submit a treatment plan for review by the third-party payer. However, please remember that the financial obligation for dental treatment is between you and this office. The third-party payer is responsible to you and not to this office.
If you receive a communication from the third-party payer suggesting that my fee varies from what they allow for the services provided to you, please do not accept this as fact without first discussing the matter with me. The third-party payer's fee data may be extremely out of date, as stated before. It may not take into consideration local factors pertaining to Suffolk County in establishing its schedule, and its geographic area may not be germane.
If, after our discussion, you believe that the dental benefits provided by your plan are inadequate, you may want to discuss the matter with your employer, union, or association, so that appropriate alternatives can be investigated.
If the red tape and lack of control that the insurance companies put between you and the proper care that you and your family deserve, bothers you, you can get more information about alternatives. Call the New York State Dental Association at 1-518-465-0044 for a free brochure entitled, "Are You Missing Out on the Dental Benefits You Deserve?" Or go to the American Dental Association's site to learn more about Direct Reimbursement. This is a means of putting more of the money your employer spends on benefit plans into care for you and less into the pockets of the insurance companies. It costs your employer less... and you get more. ADA Direct Reimbursement
I will help you in every way in filing your claims, handling insurance queries, processing follow-ups, lost claims, etc. No question is too small for you to ask, whether it is about your treatment, benefit plan, or statement. Stop in, or call, any time you have a question. I am here to help you.
Jay S. Orlikoff, DDS and Staff
Last Update February 16, 2006