About Your Insurance
Dr. Staggers’ office will assist you in filing your insurance. Dr. Staggers is a preferred provider for Delta Dental, United Concordia and Anthem, and the office will file insurance claims to ALL insurance companies. Dr. Staggers also participates in Cigna Dental Networks Savings Program. Most orthodontic policies cover $1000 to $1500 per lifetime of the child, even if Dr. Staggers is not a preferred provider for your insurance company. Some policies cover as much as $2300. Specific information about your coverage can be obtained on your insurance company's web site in the orthodontic benefits section. Please be aware that insurance policies vary and some of this information may not apply to your policy. The office staff will provide you with a form so that you may complete the patient information section. You do not need to bring a claim form from your insurance company. However, you do need the policy or group number, the policy holder's social security number and the company address where claims are to be sent. Our office can verify your orthodontic benefits online at your consultation appointment. We understand how important it is for you to get your maximum insurance benefit and will file your insurance.
Orthodontic claims are filed on two occasions. The first is for the orthodontic records. Since the records involves radiographs and a clinical examination, most dental insurance companies will cover a portion of the records fee, even if the policy does not cover orthodontic services. Typically, insurance companies cover about 50% of the records fee.
The second time an orthodontic claim is filed is for the orthodontic treatment fee at the beginning of treatment. If you would like to know what portion of the orthodontic fee your insurance company will pay prior to the start of treatment, this claim can be filed prior to the start of treatment as a pretreatment estimate. The insurance company will then send you a form explaining how much of the fee is covered and their reimbursement schedule. This information is also available in the insurance handbook given to you at the time of insurance purchase or may be obtained by calling your insurance company. Our office can also verify your benefit online at any time.
Regardless of whether a pretreatment estimate is filed, Dr. Staggers' office will file for the orthodontic treatment fee on the day that treatment is started. Orthodontic appliances must be in place in order for the insurance company to consider payment of the orthodontic treatment claim. The staff will file for the entire treatment at the start of treatment. The insurance company will consider the entire orthodontic fee once the form has been received and will decide on the amount that will be covered. The insurance company will send you a check based on what is covered under your policy. In order for the treatment fee to be covered, you must have a policy that includes orthodontic services. Most orthodontic policies cover $1000.00 to $1500.00 per lifetime of the child. General dentistry policies will not cover orthodontic services. Insurance companies reimburse claims at different rates. Most insurance companies will send checks quarterly or occasionally on a monthly basis. Insurance companies NEVER pay the entire amount covered in one lump sum.
You may call the office any time to verify when your claim was filed. The staff keeps excellent records as to when claims were filed and for what procedures. Dr. Staggers' staff have been highly trained to complete claim forms accurately and to include all of the necessary information. If you have further insurance questions, please ask the office staff, they will be happy to assist you!
Frequently Asked Insurance Questions
Does my insurance cover orthodontic treatment? Dental insurance almost always covers a portion of the orthodontic records fee since records involves X-Rays. Usually about half of the records fee is covered. In order for the braces to be covered, you must have orthodontic coverage on your policy. Orthodontic coverage is usually limited to $1000.00 to $1500.00 per lifetime of the individual. Most orthodontic policies do not cover individuals over 18 years old. New orthodontic policies may have a waiting period of 1 to 2 years. This means that you must pay insurance premiums for 1 to 2 years before orthodontic treatment is covered. Most orthodontic policies DO NOT have waiting periods.
My dental insurance covers everything, doesn’t it? What is covered by your insurance is defined by the type of plan you have. Typically the higher the premium you pay, the greater the number of procedures that are covered and the more money the insurance company will pay toward a dental procedure. Frequently higher priced, optional procedures are excluded from lower premium insurance policies. Your employer decides on the type of plan offered to you as an employee. Medical insurance policies only cover orthodontic treatment that is deemed medically necessary such as patients with cleft lip and palate or cranial synostosis. Most patient will not meet the criteria for medically necessary orthodontic treatment.
What is a preferred provider: a doctor than has signed a contract with an insurance company agreeing to provide certain services at prices determined by the insurance company. Also called an In-Network Provider.
Why aren’t all doctors preferred providers? Once a doctor signs a preferred provider contract, the insurance company controls the amount of the dental fees and what procedures are covered (paid for). The actual amount paid by the insurance company for a given procedure may not be enough to cover the costs of performing that procedure (materials, staff salaries, cost of providing an office, etc.). The end result can be that the doctor is working, but is losing money. In addition, the insurance company decides what procedures are covered, and this may force patients and doctors to make treatment decisions based on what the insurance company covers. In these instances, the insurance company, not the doctor, is dictating the treatment decisions. Doctors do not like to be in a position where an insurance company dictates treatment decisions.
Will I have to pay more for dental treatment if I do not go to a preferred provider? Sometimes, you will. Some insurance companies will require that you pay a yearly out of network deductible if you do not receive care from a preferred provider. Once you have reached your out of network deductible, the insurance company will pay your claim to your doctor even though he/she is not a preferred provider. Occasionally, insurance companies will waive the out-of-network deductible if there are no preferred providers in your town. In this instance, the insurance company will pay your claim even though your doctor is not a preferred provider. If your doctor is not a preferred provider and the charge for the dental procedure is more than the insurance company allows, you will be responsible for paying the remaining balance.
Will I pay more for orthodontic treatment if I do not go to a preferred provider orthodontist? Probably not. Orthodontic treatment is handled differently than other dental procedures by most insurance companies. Orthodontic coverage is usually limited to $1000.00 to $1500.00 per lifetime of the individual regardless of whether or not the doctor is a preferred provider. However, some insurance companies put fee limits on orthodontics treatment. I you have one of these policies, you may pay more if you do not go to a preferred provider.
Why doesn’t dental insurance cover all the costs of my treatment? Dental insurance isn’t like automobile or home insurance which cover the complete cost of a damaged car or house. Dental insurance is actually a money benefit that is paid to reduce the cost of dental treatment for the patient. It is similar to a rebate or a coupon. How much is paid and what dental procedures are covered, depends on the type of plan that you have. Typically the higher the premium you pay, the greater the number of procedures that are covered and the more money the insurance company will pay toward a dental procedure.
The insurance company says my doctor fees are above the Usually and Customary Rate (UCR). Why is my doctor overcharging me? The UCR is a dollar amount that the insurance company will pay for a given dental procedure. Insurance companies imply that the UCR is the amount that the doctor should be charging for a given procedure. In reality, it is what the company is willing to pay for the procedure. The UCR is usually less, and often much less, than what it actually costs to provide the dental care. Doctors base their fees on what it costs to deliver a given dental procedures (staff salaries, costs of the materials, costs to provide the office, etc.). An insurance company can not realistically set a cost for a procedure, unless that company actually has a practice in Winchester. The UCR is a random amount set by the insurance company. It is not the average cost charged by dentists for a given procedure in the Winchester area. When an insurance company decides on a UCR for a given dental procedure, it is like having the insurance company decide how much gasoline should cost per gallon on Valley Ave. Just because the insurance company says gasoline should cost $3.00 per gallon on Valley Ave. does not mean that you can actually buy it for $3.00.
Can I use my insurance as a down payment? No. Insurance companies will not pay any money toward orthodontic treatment until the braces have been placed. Once treatment has started, most insurance companies will pay quarterly. Occasionally, an insurance company pay monthly. Insurance companies will NEVER pay the entire benefit up front so that you can use it as a down payment.
Why didn’t the insurance pay for my X-Rays: Most policies have a limit to how many and how often X-rays will be covered. If you have X-rays taken more often than the insurance company allows (usually annually or biannually), the insurance company will not pay for them.
What good is insurance, if I still have to pay for treatment? Dental insurance is designed to reduce the cost of dental treatment for the patient, not to pay for it entirely.
Why do some insurance policies pay for more treatment? What procedures are covered and how much is paid towards a given procedure is determined by the type of plan that you have. Typically the higher the premium you pay, the greater the number of procedures that are covered and the more money the insurance company will pay toward a dental procedure. The fewer the number of procedures covered, the more restrictions on the what is covered and the more restrictions on which doctor can provide your treatment, the cheaper the insurance premium. Employers may switch to a policy with less coverage in order to save money on premiums.
My insurance doesn’t cover orthodontic treatment. Can the doctor write a letter to the insurance company stating that the treatment is medically necessary so that treatment will be covered? All dental procedures, including orthodontics treatment, have a 4 digit code assigned to them. Insurance companies pay for procedures based on whether or not that code is on the covered list. A doctor can write a letter to the insurance company explaining the need for treatment, however, this rarely makes an difference. Usually the company compares the 4 digit code for orthodontic treatment with the codes on the covered list and basis its decision solely on whether or not the code is on the covered list.
Why does it take so long for the insurance company to pay a claim? Insurance companies make money by investing premium money. Each time a claim is paid, less money is available for the company to invest. The longer it takes to pay a claim, the more time the money is invested and the more the profit for the insurance company.
I pay a lot of money for my insurance. Why don't I get better service from them? Unfortunately insurance companies do not provide the quality of service that they once did. Insurance companies are more about making a profit rather than helping patients pay for their health care. Long telephone waits on hold while checking on the status of a claim is a reality of today's insurance companies. Claims may not be processed in a timely fashion. Some companies process orthodontic claims only on one day of the month. Therefore, if your claim is not at the company on that day, it will sit around for a month until the next time the company processes orthodontic claims. Companies will frequently tell you that a claim was not received or that the doctor did not file it. You may call the office any time to verify when your claim was filed. The staff keeps excellent records as to when and what for claims were filed. Insurance companies may also tell you that the doctor did not file the claim correctly. Dr. Staggers' staff have been highly trained to complete claim forms accurately and to include ALL of the necessary information.
Important Terms to Understand About Insurance
Explanations of Benefits (EOB): a written statement provided by the insurance company explaining what procedures are covered and how much money will be paid for each procedure.
Usually and Customary Rate (UCR): a dollar amount that the insurance company will pay for a given dental procedure.
Copayment: a fee paid by the patient to the general dentist for each and every office visit (usually $15 to $25). Orthodontic treatment DOES NOT have copayments.
Coinsurance: a percentage of the fee that you must pay. For example, if you have 20% coinsurance for a certain dental procedure and that dental procedure costs $100, you must pay $20 and the insurance company will pay $80.
Pretreatment Estimate: a claim filed prior to starting treatment that will inform you of what dental procedures will be covered and how much the insurance company will pay.
Excluded Procedure: a dental procedure that is not covered by your dental plan. The insurance company will not pay for this procedure, and you will be responsible for paying the entire fee for the procedure.
Maximum Benefit Exceeded: a term used by the insurance company to mean that they have paid all that they are required to. For orthodontic treatment, this is usually $1000 to $1500.
Benefit: an amount of money that is paid by the insurance company.
Provider: the doctor providing treatment.
Preferred Provider: a doctor than has signed a contract with an insurance company agreeing to provide certain services at prices determined by the insurance company. Also called an In-Network Provider or a Participating Provider.
Insurance Participator: another term for preferred provider.
Network or Insurance Network: all of the doctors that are preferred providers for a given insurance plan.
Out-of-Network Provider: a doctor that has not signed a preferred provider contract with an insurance company.
Deductible: an yearly amount that you must pay before the insurance company will start paying claims. Insurance plans may have several types of deductibles (Out-of –Network, In-Network, Outpatient, Lab, Hospital, etc.).
In-of-Network Deductible: an yearly amount that you must pay to doctors who are preferred providers before the insurance company will start playing claims.
Out-of-Network Deductible: an yearly amount that you must pay to doctors who are NOT preferred providers before the insurance company will start playing claims. Out-of-Network Deductibles are usually higher than In-Network-Deductibles.
Out-of-Pocket Expense: money that you must pay toward the dental bill.