If you have questions about your insurance coverage, please let us know. We will be happy to contact your insurance company prior to treatment to provide a complimentary estimate of your benefits. This sounds simple, but it is not.
Insurance is very complicated.
It is different for every patient.
Policies and coverage change frequently.
The terminology used leads to great confusion.
Variables in insurance coverage: Many of our patients have dental insurance. Benefits vary widely from company to company, and from policy to policy within the same company. While some policies provide full coverage of the treatment Marks Family Dentistry provides, other policies provide very little. Some policies provide full or almost full coverage for some treatment, and for the same patient, very little or no coverage for other treatment. The most common variables and the language that complicates the process are:
"in" network or "out of network"
"participating" or "non-participating"
"contracted" or "not-contracted"
It is very important that you realize your policy is with your employer and your insurance company. Marks Family Dentistry has no control over your benefits. Our dentists and hygienists make recommendations regarding your dental health based on their professional expertise. At no time is our recommended treatment determined by the amount an insurance policy will pay for a patient's care. Our goal is, and always has been, to determine what is in the best interest of the long-tem overall health of our patients. Therefore, we are not a "participating provider" with any insurance company.
What does "in" and "out of" network mean? For some insurance companies it does not make a difference whether Marks Family Dentistry is "in" or "out of" network; however, for other companies, going "out of" network does make a difference. The difference is the "allowable fee" of the insurance company. The "allowable fee" refers to the amount your policy pays for a specific treatment based a contract between your employer and your insurance company.
Your insurance company or your employer may say you have 100% coverage for preventative care--that means 100% of the insurance company's allowable fee. The "allowable fee" is the limit your policy will pay. Sometimes the "allowable fee" is more than our fee, and sometimes it is less.
For example: The Marks Family Dentistry fee for a procedure is $100.
1. If the insurance company's "allowable fee" is $120, the insurance company pays $100, the patient pays $0
2. If the insurance company pays 100% of their "allowable fee," and their "allowable fee" is $85, the insurance company pays $85 and the patient pays $15.
3. If the insurance company policy is to pay 80% of their "allowable fee," and their "allowable fee" is $100, the insurance company pays $80, and the patient pays $20. However, if the insurance company's "allowable fee" is $80, the insurance company pays 80% of $80, which is $64, and the patient pays the remaining balance of $36.
What does "participating" or "non participating" mean? If a dental office participates with an insurance company, the office accepts the insurance company's allowable fee or percentage of allowable fee for treatment . If a dental office does "not participate," the office accepts the insurance payment as partial payment, and the patient is responsible for the remainder of the fee.
Why doesn't Marks Family Dentistry participate with my insurance company or accept HMO/DMO policies? We have found that being bound to the provisions of insurance contracts can impact the quality of care our patients receive. The benefits allowed by an insurance company are determined by what the employer provides as coverage to its employees. Unlike medical insurance, there are not laws that mandate adequate dental care. When insurance companies discount fees to the extent that many do, it adversely affects the quality of care you receive, the quality of materials that can be used, the quality of the dental labs we are able to engage, and even many modern procedures that provide a much better and more cost effective result for our patients.
What does "basic coverage" mean? Some policies have " basic coverage," others do not. "Basic coverage' provides minimum insurance coverage. Restorative treatment, such as "fillings" is addressed in "basic coverage." For many insurance companies "basic coverage" for a filling allows the fee for an amalgam filling (also known as "silver " or "mercury" fillings) no matter what the dentist's recommended treatment may be. Marks Family Dentistry has not placed an amalgam filling since 1995. We would not use this treatment for our family and will not use it for our patients. We use composite resins because we believe they are stronger, more compatible with your own teeth, and more pleasing esthetically. They are also more expensive, but we believe they are worth it. We make all of our recommendations for treatment based on what we believe is best for a patient's oral health, not based on or modified by what insurance pays.
Marks Family Dentistry files with all insurance except HMO/DMO policies and Medicare or Medicaid. For new and existing patients we make every effort to research benefits and determine what will be covered prior to treatment. After treatment we file claims and work with our patients and their insurance companies to help our patients maximize the benefits of their policy. But in the end, our recommended treatment will always be based on our professional expertise, and never on insurance coverage.
Over the years we have had a number of patients go elsewhere because of concerns about insurance. Many of them return to Marks Family Dentistry because they realize immediately they are not receiving the same level of care.