Dealing with insurance carriers creates many problems for dental offices. Problems with Explanation or Estimate of Benefits (EOB), post-payment utilization review, and payment delays are only a few of the issues offices deal with on a daily basis. What follows are answers to some common questions and simple answers.

The following are some of the PPOs that we accept at our office:


• MET Life (877) 638-3379 

• The Guardian (800) 541-7846

• AETNA PPO (800) 872-3318

• Mutual of Omaha (402) 342-7600

• Delta Dental (888) 335-8227

• Cigna PPO (800) 252-2091 

• United Concordia (800) 541-7846

• Ameritas PPO (800) 336-6661

• Principal Financial (800) 826-1820

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Why do some insurance rules go against proper dental procedures and services?

Most insurance carriers employ attorneys who help set up the plans. Remember, plan parameters, or "rules" are designed to sell plans and/or make money, not fully fund the most appropriate treatment.

Why do carriers deny a claim?

Carriers deny claims based on the parameters of a patient's contract. If a service is not covered in the contract, it will not be a benefit, regardless of dental or medical need and regardless of its format.

What can I tell patients who tell me that their plans cover exams and certain other procedures at 100 percent?

The "100 percent," as defined by the insurance carrier, is actually just what the insurance carrier "allows" as its 100 percent or full payment toward a procedure. It bears no relationship to what our office may actually charge. For example, our office may charge $80 for an exam. The insurance carrier may allow $60 as its 100 percent payment for that examination, leaving $20 for the patient to pay.

Why do carriers stall 30-60 days or more on claim payment?

Turn-around times on claims are slow. It is to the insurance company's benefit to release the payment as late as possible.

How do carriers come up with "usual and customary" fees?

Insurance plans typically base their fees on one of two systems: "charging patterns' or "relative-value scales." Charging patterns usually are based on a data pool of charges for each section of the country. Relative-value scales are based on studies of what goes into each type of dental procedure. The exact method used by each insurance carrier and the actual fees and "percentiles" set for each plan are considered to be trade secrets and are not revealed to patients or dentists.

An insurance carrier presents several percentile levels and related premium payment amounts to employers buying the plans. Whatever plan is selected by the employer becomes the set fee schedule or "UCR" fee schedule for that plan. The term "UCR" might more accurately be called a "negotiated fee." UCR is simply what is considered the accepted fee for each particular plan, as negotiated between the employer purchasing the plan and the insurance carrier providing the plan.

Can patients obtain a list of codes and a carrier's allowed benefits for each code?

Theoretically, this should be allowed under federal labor law for plans covered by ERISA. (ERISA stands for the Employment Income Security Act of 1974, which was put in place to protect employee pensions and company self-funded plans from "excessive" state regulation.) In fact, in 1996, a federal Labor Department "advisory opinion" stated that "usual and customary" fee schedules used to determine insurance benefits for companies falling under the ERISA Act are "instruments under which the plans are established or operated" and must be given to participants of the plans when requested in writing. However, few, if any, patients have ever obtained this information. Carriers regard the allowed amounts as trade secrets and will not reveal them.

Can offices obtain the allowed amounts and inform patients?

No. It is possible to purchase a general-fee profile, known as the Prevailing Healthcare Charges System. It is commonly used by carriers to determine fees by code for each zip code area in the country. This fee profile system is extremely expensive and the information is not specific for each plan.

Why do carriers refuse payment for panographs and other X-rays when taken the same day?

More than 10 years ago, many carriers eliminated payment for a full-mouth series of radiographs and a panograph when taken on the same day - or even within the same three year period. (Most carriers consider seven periapicals as a full-mouth series, despite the fact that most dental personnel consider this to be 14-18 films.) Some carriers now are eliminating payment for any PA's taken on the same date as a panograph.

How can an office file a complaint with the insurance commissioner?

State insurance commissioners are given the task of protecting the consumer, not the dentist. However, if a certain company has many complaints, it might affect their ability to continue business in a state. A patient letter, email, or a letter from an employer usually pulls more weight.

Most state insurance commissioners have Web sites for obtaining addresses, phone numbers, and email addresses.

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