Pediatric Dental Insurance & Payment Policies
At Southern Smiles Pediatric Dentistry in Cary, NC, the health and well- being of your children are our top priorities. Our focus is on building relationships with your child rather than with their dental insurance carrier. We are committed to helping your child thrive and will make care recommendations that align with that goal. Regardless of your insurance plan, our pediatric dental team will always present treatment options based on your child's oral health needs, not on what insurance covers.
We will also do our best to help you understand your dental insurance benefits and in most instances, we are able to file your dental insurance claim for you electronically. This will help ensure you are able to maximize your dental benefits. When permitted by the insurance carrier, we will accept assignment of insurance benefits for treatment of services (meaning insurance benefits will be paid directly to our practice), in which case patient families are responsible for their regular co-pay, deductibles and any non-covered expenses the day services are rendered. If your insurance carrier does not allow our practice to accept assignment, payment for services rendered will be collected in full, from the patient family, on the day the treatment is provided.
In the event the insurance carrier pays out less than estimated, patient families are financially responsible for the difference. For specific information regarding which carriers/policy types we are ‘in-network’ with, please contact our administrative team. We will keep you updated on any changes to our insurance status at the time of your appointment and we ask that you update us as soon as possible if there are any changes with your policy or your carrier. Our goal is to keep you well-informed about potential costs before, during, and after treatments.
A trend in dentistry is for families to move from one dental home to another based on dental insurance coverage changes that occur with the company/ employer parents work for. We know that the most important predictor of good oral health for your children into adulthood is based on the continuity of care, relationship building, and the ability for a doctor to truly know your children as they grow and develop. This is one of the reasons we keep most children in our practice through the college years. In the event that you insurance changes, please carefully consider the importance of maintaining a secure consistent dental home for your children.
A Few Basics on Insurance
Co-Pay versus Deductible
A deductible is the amount of money you pay for covered dental services before your insurance plan starts to pay.
A copay, or copayment, is a fixed amount of money a patient with dental insurance pays for a covered service. The amount of the copay can vary by the type of service.
Carrier versus Plan
A Dental Carrier is a dental insurance company, dental services corporation, or dental plan organization authorized to provide dental benefits, or a health benefits plan that includes coverage for dental services.
In-Network versus Out-of-Network
Dentists who work In-Network are also known as participating providers. They are contracted with an insurance company and have agreed to provide dental services at pre-negotiated rates.
You may still have to spend out-of-pocket money because depending on the plan you have, a copay or deductible may be required.
Dentists who are Out-of-Network do not contract with an insurance carrier and do not have pre- negotiated rates. Rather the dentist sets the fee and you are responsible for any amount not covered by your insurance plan.
Assignment versus Non-Assignment of Benefits
Assignment of benefits is a covered person’s consent to authorize payment of benefits directly to a dentist.
Non-Assignment of Benefits means we will file the claim and the insurance carrier will pay the primary subscriber. The patient would be responsible for paying the full cost of treatment at the time of service.
Insurance Myths
Myth #1
Insurance companies work with dental offices to determine what benefits your child should truly have and what the actual true cost is for the pediatric dentist to provide the treatment necessary to care for patients. This is not the case at all.
What actually happens is that insurance companies set their own fee “schedules,” and each insurer uses a different set of fees that they will allow for various types of dental treatment. Those fees are referred to as “allowable” fees. The amount of money the insurance company has decided should be charged for a procedure is known as the UCR fee (usual, customary, or reasonable), and it varies widely across thousands of plans and companies.
When an insurance company reimburses you less than the dentist’s actual fee, and the explanation provided is that the fee charged is higher than the UCR, this implies that the dentist has charged an unusually high fee that is not customary and is unreasonable. Giving the impression that your dentist is overcharging when the insurance company has built in a 20-30% profit margin for themselves is not only inaccurate, it is misleading and unethical.
Myth #2
My insurance will pay 100% of all procedures if my dentist is in network with my insurance. When asked, most people believe that dental insurance pays 85%-100% of all your dental fees.
The reality, in general, is very different and, on average, ranges from 50% to 80%. Dental insurance rates are negotiated between your employer and the insurance company and there are literally thousands of network plans available. Our goal is to focus on being experts in taking care of you and your children. The more time we spend on insurance, the less time we have for your child.