Fact #1 - Not all dental insurance has orthodontic coverage
times the dental insurance that you might have does not have an
orthodontic benefit. The only way to tell for sure, is to contact your
insurance company directly and check to see if there is an orthodontic
Fact #2 - No Insurance pays 100% of all procedures
Orthodontic Insurance is meant to be an aid in affording
orthodontic care. Many patients believe that their insurance pays
90%-100% of all of their orthodontic fees. This, unfortunately, is not
true. Most plans will pay up to 50% of the charged fee, up to a maximum
limit ($1000, $1500, $2000, etc.). Some pay more,..., some pay less.
The percentage and amount paid is usually determined by how much you
and your employer have paid for the coverage, or, the type of contract
your employer has set up with the insurance company.
Fact #3 - Benefits are not determined by our office
You may have noticed that sometimes your orthodontic insurer reimburses you at a lower rate
than the orthodontist's actual fee. Frequently, insurance companies
state that the reimbursement was reduced because the orthodontist's fee
has exceeded the usual, customary, or reasonable fee ("UCR") used by the company.
Unfortunately, a statement such as this gives the impression that any
fee greater than the amount paid by the insurance company is unreasonable or well above what most orthodontists in the area charge for a certain service. This can be very misleading, and simply is not accurate.
Insurance companies set their own schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from the claims that it processes. The insurance company then takes this data and arbitrarily
chooses a level they call the "allowable" UCR fee. Frequently, this
data can be three to five years old and these "allowable" fees are determined
by the insurance company so that they can make a net 20%-30% profit.
Therefore, insurance companies will often imply that your orthodontist
is "overcharging" rather than say that they are "underpaying" or that
their benefits are too low.