The Insurance Department of Village Family Dental has undergone various stages of training and is dedicated to serving our patients’ needs as well as those of our staff. They have a working knowledge of insurance company policies and procedures and keep the office current on plan or policy changes.
The Insurance Coordinators are responsible for performing a variety of tasks including filing claims, posting insurance payments and overseeing the entire insurance process. They are available at any time to answer your questions.
We make every effort to obtain our patients’ dental insurance information over the phone when they schedule their first visit. This allows our insurance department the opportunity to obtain a summary of dental benefits prior to the appointment and to help facilitate the new patient process.
Once it is verified that a patient is eligible for benefits, a summary of their coverage is selected for their account. Once treatment is determined, a treatment plan will be entered into their account, presented to and signed by the patient as consent before treatment begins. We collect the anticipated patient portion at the time of service and file an insurance claim for reimbursement to be paid directly to our office. Once the claim is processed, any amount paid will be applied towards the account. Occasionally, claims will be denied or more information will need to be provided. The Insurance Department will ensure that the claim has been processed and all means necessary have been taken to receive reimbursement. If there is a difference in the estimated insurance coverage and the actual amount paid or the claim is denied, then the patient is ultimately responsible for the balance. Patients must understand that our treatment plans are only estimates and insurance companies are not always predictable.
Village Family Dental participates with a few dental carriers. We participate with BCBSNC, Cigna PPO (Total PPO), Delta Dental Premier, HealthSmart coverage for Cumberland County Schools and PWC, MetLife and United Healthcare. Some locations within Village Family Dental participate with United Concordia. We are also providers with the Medicaid and NC Health Choice programs. Even though we do not participate with all insurance companies, we will file all claims as a courtesy to our patients.
Usual, Customary and Reasonable Charges
Insurance companies reimburse on a set of established fees that they call their UCR or Usual, Customary and Reasonable Charges or MAC, Maximum Allowable Charge. These fees may be less than our actual charge. This doesn’t mean that we overcharge our patients. Instead insurance companies are not regulated to keep their fees up-to-date necessarily for our region. The cost for quality dental care has risen over the years but the level of dental benefits has remained the same.
We bill our full fee to insurance companies and they process the claim based on their UCR fees. Thus, if they cover 80% of an endodontic procedure, then they will process at 80% of their UCR fee, not our submitted fee. See the following example:
We will always provide a treatment plan to be signed, either by the patient or their legal guardian, prior to rendering any dental services. This serves as consent as well as the acceptance of responsibility for any balance that is due.
Many details are taken into consideration when preparing treatment plans such as deductibles, waiting periods, frequency limitations, etc.
Many of our patients will provide us with two dental policies. We file the primary policy and upon payment we will forward the claim to their secondary policy along with an EOB or explanation of benefits from the primary policy. The EOB is a payment statement showing how much was paid and how the claim was processed. Any policy that is considered to be secondary will require the primary EOB before the claim can be processed.
Treatment plans for any major procedures (crowns, bridges, etc.) will only reflect payment from the primary policy. These procedures tend to have exclusions in the fine print, such as: a missing tooth clause, a prosthetic replacement clause, a non-duplication (or carve out) clause and the “primary has paid the allowable amount” clause. Insurance companies do not provide us with comprehensive benefit information. Therefore, we do not know the limitations and rules they use to determine benefits. What this means to our patients is that their portion will be based upon one policy. However, we will still file the secondary policy for them and any over payment will become a credit on their account.
Patients may request for us to file a pre-estimate prior to scheduling their treatment. A pre-estimate will allow us to better estimate the amount of their payment portion in advance. However, it should be kept in mind that this is not a guarantee of payment. We may suggest these to our patients when they have large treatment plans or are in need of extensive prosthodontic procedures.
We will file the pre-estimate, accompanied by all necessary documentation, to the insurance company. The average response time is four weeks. Once we receive the processed pre-estimate, we will create a treatment plan based upon the explanation provided. The patient or guardian will then be contacted to schedule the treatment.
Most insurance companies will not require a prior-approval. Many simply suggest or recommend them if the treatment is over a certain dollar amount. As previously, explained, we are still capable of filing them upon patient request.
To help our patients facilitate the cost of their treatment, several payment plans are available to them. These financial services are separate from Village Family Dental and result in a contract between the patient and that financial institution. These plans are utilized for large treatment plans, cash patients and services that insurance companies do not cover.
Care Credit is a leader in patient financing. With a comprehensive range of payment options, for treatment or procedures from $1,000 to over $25,000, Care Credit offers a plan and low monthly payments to fit nearly every budget. There are no interest plans and extended payment plans available. Patients may apply by application from our office, online, or by calling the toll-free number.
Lending Club provides quality financing for patients with larger treatment plans that extend from $4,000.00 to over $32,000.00. Extended plans offered through Lending Club Patient Solutions provide some of the most flexible and lowest monthly payments. Plus, True No-Interest Plans with no retroactive interest avoid unwelcome surprises. Patients may apply in-office, online or by calling the toll-free number.