UCR (Usual, Customary & Reasonable)
Under a UCR plan, patients are usually allowed to see the dentist of their choice. These plans pay an established percentage of the dentist’s fee or pay the plan sponsor’s “customary” or “reasonable” fee limit, whichever is less. Although these limits are called “customary”, they may or may not reflect the fees that area dentists charge.
It may also be noted on your receipt the fee that your dentist has charged you is higher than the reimbursement levels of UCR. This does not mean your dentist is overcharging you. For example, the insurance company may not have taken into account up-to-date, regional data in determining a reimbursement level.
WHY??? There is no regulation as to how insurance companies determine reimbursement levels, resulting in wide fluctuation. In addition, insurance companies are not required to disclose how they determine these levels. The language used in this process may be inconsistent among carriers and difficult to understand.
Your plan purchaser makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company.
Even though the cost of dental care has significantly increased over the years, the maximum levels of insurance reimbursements have remained the same since the late 1960’s! Many plans offer higher maximums that are comparable to rising dental care costs.
Your plan may want you to choose your dental care from a list of their preferred providers. Whether or not you choose your dental care from this defined group can affect your levels of reimbursement.
Least Expensive Alternative Treatment
Your dental plan may only allow benefits for the least expensive treatment for a condition. For example, your dentist may recommend a crown, but your insurance may only offer reimbursement for a large filling. As with other choices in life- such as purchasing medical or automobile insurance, or buying a home- the least expensive alternative is not always the best option.
Just like your medical insurance, your dental plan may not cover conditions that existed before you enrolled in the plan. Even though your plan may not cover certain conditions, traetment may still be necessary.
Your dental plan may not cover certain procedures, or preventative treatments that can save you money later. This does not mean these treatments are unnecessary. Your dentist can help you decide what type of treatment is best for you.
IF YOU HAVE QUESTIONS REGARDING YOUR DENTAL PLAN, OR A PROBLEM WITH A REIMBURSEMENT LEVEL, CONTACT YOUR EMPLOYER OR INSURANCE COMPANY.
Although our front desk staff can help explain dental plan issues to you, your dentist may not be able to answer specific questions about your dental plan, or predict what your level of coverage for a procedure will be. This is because plans offered by the same employer or written by the same third-party payer can vary according to the contracts involved.
The American Dental Association recognizes the important role dental benefits have played in improving access to dental care for millions of Americans, and is working with insurance policymakers to help set better standards within the industry.
For additional information regarding dental plans, contact the American Dental Assocation, Council on Dental Benefit Programs, 211 East Chicago Avenue, Chicago IL 60611; email: [email protected].
(Reprinted from “Why Doesn’t My Insurance Pay For This”)