Dental insurance can be a valuable resource for people seeking to manage the cost of dental care. However, understanding how insurance companies determine the amount they’ll allow for procedures can be a bit of a mystery! If you’ve ever wondered how dental insurance companies decide on reimbursement rates, this blog post explores the difference between contracted, UCR, fee schedule, and DMO plans.
First, the basics: if a plan tells us they’ll help with 80% of a filling, what they are really saying is that they will help with 80% of the allowed amount of that filling. How that allowed amount is calculated depends on the kind of plan you have.
Contracted provider: In this case, we have a set contracted rate with an insurance company, and they agree to pay a certain percentage of that fee for care provided. This is also known as being “in-network.” Our contracts with in-network insurance companies don’t allow us to offer discounts for seniors or prepayments, write-off balances, or provide special offers.
UCR PPO: These plans pay our office based on “Usual, Customary, and Reasonable” fees. An insurance company will calculate the average cost of a specific dental procedure within our zip code and reimburse us based on that amount. It will vary between insurance companies. Some employers also choose a higher UCR level when purchasing an upgraded plan, so even within the same insurance company, you may see different UCRs depending on the policy! Our fees typically fall within the allowed UCR for most major insurance companies.
Fee Schedule PPO: Also known as “Maximum Allowable Charge,” these plans reimburse non-contracted providers according to a fixed fee schedule determined by the dental insurance company. They don’t usually consider location or average costs for care, so in Manhattan, they are typically much lower than the standard UCR reimbursement schedules above. The reimbursement schedules vary widely by insurance company, and they don’t always disclose the fees. For plans like this, we’ll collect in full on the day of service and then take care of all the paperwork for you to be reimbursed directly.
HMO/DMO: A DMO is a network of dentists who provide services at a fixed cost. To receive any benefit at all from a DMO plan, you need to visit a participating provider. Dentists who are contracted in these plans are “pre-paid” a fixed amount every month for each person assigned to the practice. In exchange, they are required to provide certain services either at no cost or at substantially reduced rates. The dentist selected by the patient serves as a gatekeeper and is responsible for determining if someone should be referred to a specialist for treatment. We’re not currently participating in any DMO plans, so your care would be out of pocket.
It’s important to note that insurance companies use much more than just the above to determine the final coverage for a given treatment. Other factors like deductibles, downgrades, age limits, co-payments, and annual maximums also impact your out-of-pocket cost for care. We always do our best to provide an accurate initial estimate based on the information your insurance company gives us, but keep in mind it is just that – an estimate. Your dental insurance is a contract between you, your employer, and your insurance company. Our focus is on providing you with the best clinical care and patient experience possible. If, for any reason, insurance pays less than we expected, you will be responsible for the balance due.
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