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Insurance network change faqs

What is changing?

Q) What is changing?

  • Starting on December 15th, 2022 our office will be considered Out of Network (OON) providers, but we will still accept your insurance, just like we always have.  If your current insurance plan includes OON benefits, then your insurance will still pay towards the cost of treatment in our office. If your current plan does not include OON benefits, then your insurance company will only pay towards the cost of treatment with an in-network provider.  

What do you mean by

Q) What do you mean by in-network and out of network?

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Out of network

Q) Why would you go out of network? 

  • Our Patients - Our patients are obviously why we do what we do and why we exist.  Providing the best care possible for our patients is not an inexpensive task.  The training, materials, equipment and time that goes into providing the best care possible is only getting more expensive.  If we limited our quality of care to the level that insurance actually reimburses us for, we would not be able to provide the same experience and care for our patients.  We would have to squeeze more appointments into our schedule and be forced to spend less time with our patients.  Just like any office, we sometimes get busier than we would like, but that is due to unforeseen complications during treatment, or trying to accommodate patients experiencing a dental emergency. True insurance/volume driven offices will intentionally shorten appointment times to squeeze in as many patients as they can see in a day.  One reason our availability is so limited for cleanings is because we are not shortening our appointments because we don’t want to shorten the time that you have with our providers.   Our focus is to provide the best care that we can in a warm, caring and comfortable environment.  Insurance company’s focus is to pay the least amount of benefits to help increase their profits by millions of dollars. 

  • Our Team - Our doctors could not do what we do without our amazing team of hygienists, assistants and administrators.  Due to the rising cost of living and historical inflation, we want to make sure our excellent employees are appropriately compensated.  Even though these rising costs and inflation are well known and apparent in all aspects of life, insurance companies have not increased our reimbursements in over 7 years.  We care about our staff and want to be able to offer them competitive benefits, bonuses and salaries.  We also want to make sure our staff can enjoy their free time with their friends and families, and enjoy the beautiful area that we call home.

  • Our Practice - There are certain reasons that patients choose a particular dental office to be their dental home.  We like to think that the reason you have chosen us is because of our providers, team, and how we run our business.  Our mission statement (which has not changed since we started Elevated Dental in 2017) is: “Provide the best possible care and experience to improve the health and life of patients in a friendly, professional, and organized environment, while creating a positive and productive team mentality to allow everyone to enjoy life both inside and out of the office.”

These are the qualities that matter to us and our practice.  These are not qualities that matter to a dental insurance company.  We will not be forced into changing our business practices and clinical care to match the greed of insurance companies.  For our practice to stay true to our values, we need to remove ourselves from the inequitable relationship of being an in-network office.

What if my insurance doesn't

Q) What if my insurance doesn’t have any OON benefits?

  • If your insurance has zero or minimal OON benefits, you can ask your insurance carrier or employer to add to or improve that.  Not only would this increase the amount of benefit you may receive at our office, but we have heard from quite a few patients that they left their previous dentist because they “stopped taking their insurance”.  Having OON benefits gives you more flexibility and choice as to what dental office you see with minimal change in costs.  While improvements in coverage between different medical plans can mean a large increase in monthly cost, the cost difference between dental plans is comparatively small.  If there is a significant monthly premium cost increase, there are always membership plans that most dental practices offer.  We do offer our Elevated Care Plan, which is financially advantageous for many patients compared to most private dental plans that are available.

How much will it

Q) How much will it cost me to get treatment now?

  • Since there are thousands of different insurance plans (another way insurance companies create confusion for both patients and offices), it is impossible to answer that question on a broad scale. The table below shows some samples of in-network versus out-of-network benefits.  As you can see, some plans do have less coverage for out-of-network offices, but that is because of the details of that particular plan.  Almost all dental insurance plans can offer OON benefits, if requested.  If you'd like to know how this change will affect you and your plan, specifically, we are happy to help you with getting you a basic breakdown of your plan’s out-of-network coverage. Please e-mail our office at info@elevateddentalvail.com and please allow 1-2 weeks as we are expecting a lot of requests for this information. 

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We are also happy to submit a pre-determination prior to treatment, but please keep in mind that dental insurance pre-determinations are not a guarantee of payment.  They are often not based solely on plan benefits without review of xrays, clinical notes or other supporting documents. 

Do you offer

Q) Do you offer any financing & other options for helping pay for dental treatment

  • For the times when finances may prevent patients from accepting recommended dental treatment, we will still offer in-house payment plans for short term payment plans.  For longer term payment plans, we will offer Sunbit Financing. With Sunbit, specific financing options will vary patient to patient, often including at least one 0% APR option and payment plans up to 72 months. There is no hard credit check and it only takes ~2 minutes to see what your options would be. Please use this link to learn more and to see which options you qualify for: https://apply.sunbit.com/ElevatedDental-Vail

  • If you are in true financial hardship, there are grants and funds that can help with costs.   The Vail Valley Charitable Foundation’s Eagle County Grins program can help cover the cost of dental treatment for adult patients experiencing financial hardships.  There is also a public health clinic in Frisco that sets fees for treatment on a sliding fee scale based on income.

Questions to ask

Q) What questions should I ask my insurance about OON coverage?

Our team verifies that your plan is active and collects basic benefit information from the insurance company in order to submit claims and calculate estimated copays but it is ultimately the patient’s responsibility to understand the benefit and network restrictions of their specific dental insurance plan. We highly advise our patients to familiarize themselves with the details of their dental insurance plan. Below are some of the questions we feel are important for patients to ask their insurance company:

Questions to ask (basics - more information about these in section below):

  • What are my out of network benefits?

  • What’s Annual Max & Deductible - and what types of services does my deductible apply to

  • What are the coverage percentages for: preventive, basic, major, implant

  • How frequently will my plan cover: cleanings, exams, xrays?

  • What is my “plan year” (when does my plan reset each year)?

  • Is there a “waiting period”?

  • Is there a “missing tooth clause”?

  • Are there any material downgrades?

  • Is assignment of benefit to the provider accepted for out of network providers?

  • “What is the maximum allowable charge for X, Y & Z codes if I were to see an out-of-network provider?

  • Ask for specific fees below. If they won’t give you that, ask if our fees are within or above their MAC/UCR.

  • Check Codes/Fees:

    • D1110 - Prophylaxis (dental cleaning)  - $138

    • D0120 - Periodic Exam - $70

    • D0210 - Full Series X-ray - $185

    • D0274 - Four Bitewing X-rays - $86

    • D2391 - 1-Surface Filling - $266

    • D2740 - Porcelain Crown - $1565

    • D2950 - Build-up (often required with a crown) - $325

    • D7210 - Surgical Extraction -  $390

  • Please Note: Your annual maximum applies to ALL services. If you reach your annual maximum benefit, your insurance will not pay for ANY other services (including cleanings & exams) until your plan year resets. 

Questions to ask (same questions, just with a little more explanation)

  • What are my out of network benefits? - Are there out of network (OON) benefits? If there are NO out of network benefits (ONN), you'd need to see an in-network provider for the insurance to contribute towards the cost of treatment. MOST dental plans include at least some out of network benefits, many offer OON benefits that are quite comparable to the in-network benefits. Having OON benefits allows patients the freedom to choose their provider based on their own preference. 

  • What is my annual maximum benefit? What is my annual deductible and does it apply to preventive services? The standard annual maximum is ~$1500. This means that you insurance will not pay more than $1500 towards your dental claims in any given plan year. The most common deductible is $50-$100 and does not apply to preventive services. If your plan’s deductible does apply to preventive services, then you would need to pay that deductible at your first visit of the plan year, even if it’s just a cleaning visit. 

  • What is my “Plan Year”? Most plans run on a calendar year, which means the annual maximum and deductible reset every January. However, the plan year can vary from plan to plan. It’s important to know when your plans benefits reset each year. 

  • Coverage percentages for:

    • ​Preventive/diagnostic

    • Basic

    • Major

    • Implant

    • Ortho 

  • Standard coverage is: 100% preventive, 80% basic, 50% major and if there is implant and/or ortho coverage, those are usually 50% too. 

  • Typically,” preventive/diagnostic” services are things like cleanings, exams and most xrays. Fillings are typically considered “basic” services. Things like crowns & bridges are often considered “major” services. 

  • How frequently will my plan cover: cleanings, exams, xrays?Ask about frequency limitations for the following code:

    • D1110 - Prophylaxis (standard dental cleaning)

    • D0120 - Periodic exam (there are several types of exams and typically, they all share frequency. 

    • D0274 - 4 Bitewing Images (there are the xrays we take annually)

    • D0210 - Full Mouth Series Xrays (we recommend a full series xrays be taken every 3-5 years)

  • Is “assignment of benefit” to the provider accepted for out of network providers? They will likely say either, “as long as there is a signature on file” or “no”. As long as assignment of benefit is accepted, the option for payment to be sent to the provider exists. If it’s not accepted, insurance payment will only go to the patient, so we (the provider) will have to collect in full, up front, for treatment and the patient would be reimbursed by insurance. 

  • Is there a “waiting period”? If there is a waiting period, how long is it? And what types of services does it apply to? If there is a waiting period, your insurance won’t contribute towards that type of service until the waiting period has been met (and until you’ve paid for the plan for that long). Most frequently, we see waiting periods that last 6-12 months and do not apply to preventive services like cleanings and exams. 

  • Is there a “missing tooth clause”? If there is a “missing tooth clause”, the insurance won’t pay for the restoration of a tooth that was extracted prior to the start of the plan’s coverage. So if you had a tooth extracted prior to the start of your insurance coverage, the new plan won’t contribute towards the cost of a bridge or implant to replace that extracted tooth. 

  • Are there any material downgrades? Some insurance plans still include a clause so that they can elect to only pay towards the cost of amalgam (silver) fillings or metal crowns on posterior teeth (those teeth that typically don’t show in your smile). These plans consider composite (white) fillings and porcelain crowns an “elective upgrade”, despite the fact that these have been the standard of care for all teeth for decades (there are still some specific instances in which amalgam fillings or metal crowns are the more ideal treatment, but it’s not very often). The insurance will pay the covered percentage of the lower fee and the patient is responsible for the difference.

  • “What is the maximum allowable charge for X, Y & Z codes if I were to see an out-of-network provider?” - Just because a plan says it covers 100%, does not mean it covers 100% of the fee we (or any other office may) charge. When patients see an in-network provider, that provider has agreed to a set “fee schedule”. These are fees set by the insurance company and the in-network provider is contractually obligated to charge for covered services. Maximum Allowable Charges (MAC) or Usual & Customary Rates (UCR) are the usual terms for the dollar amounts that insurance companies use to process claims for out of network providers. Most UCR rates are well above our office fees, so 100% coverage actually means 100% coverage. But occasionally, the MAC/UCR is lower than our office fee, which would mean insurance will pay 100% of that lower fee and leave the patient  responsible for anything above it.  See example below:

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  • Ask them to provide the fees for the codes listed below. If they won’t give specific fees but will tell you if a given fee is "above or within", use our fees for comparison. Below are some of our most commonly used codes and corresponding office fees:

    • D1110 - Prophy - $138

    • D0120 - Periodic Exam - $70

    • D0210 - Full Series Xray - $185

    • D0274 - Four Bitewing Xrays - $86

    • D2391 - 1-Surface Filling - $340

    • D2740 - Porcelain Crown - $1565

    • D7210 - Surgical Extraction -  $390

Why would I

Q) Why would I risk having to possibly pay more to see you when I could just go find another in-network provider?

  • Our fees are based on regional averages, that take into account local cost of living.  So our fees are very comparable to other offices' OON fees.  A dental office is not a low-overhead enterprise. We pride ourselves on utilizing quality materials, current technologies and our incredible team of clinicians and administrators. We also strive to spend more time with our patients, not less. More and more, in-network providers are having to make the call between finding ways to cut out other expenses or see more patients in less time.  Most in-network privately owned practices are currently moving in the direction of becoming OON offices.  

New fees

​​​​​Q) What will be your new fees?

  • When Southwest Airlines started marketing “Transfarency”, we were very impressed with that concept.  We try to be as straightforward as possible when it comes to costs and fees.  That is why we are trying to provide as much information as possible in regards to this transition to out-of-network providers.

  • In 2017, CO passed a bill called SB17-065 “Transparency In Direct Pay Health Care Prices”.  This made it necessary to have health care providers disclose charges they impose for common health care services when payment is made directly.  

  • This list of the 15 most common services should be available on a provider’s/office’s website.  Here is a link to our list and it can be found under our Patient Forms page on our website.

  • We are happy to be open about our fees, as long as there is an understanding that there are many clinical situations where multiple services/codes are needed for an acceptable clinical outcome. For example, some crowns need an adjunctive procedure called a core build-up and some crowns do not.  

Med vs. Dental

Q) What is the difference between medical and dental insurance?

  • The biggest difference between medical and dental insurance is who the out-of-pocket maximum applies to:

    • In medical insurance, the patient has an out-of-pocket max​

    • In dental insurance, the insurance company has an out-of-pocket max

      • For example, should you get into a car accident (we obviously hope that never happens, but that is why we have insurance) and end up with a $15,000 medical bill.  Your insurance (depending on the plan)​ will usually require a patient to pay upwards of $5,000 then pay the rest of the bill.

      • If you have the same scenario, but incur a $15,000 dental bill, your dental insurance will only pay up to $1500 ($2000 on the highest end plans) and you are responsible for the remainder of the bill.​ ​

  • When it comes to pre-determinations (or pre-authorizations) medical will usually stand behind their determination on whether or not a procedure will be covered.

    • Dental insurance always has fine print at the bottom of the pre-determination that says "This is not a guarantee of payment"​

    • Dental insurance also takes weeks to respond with the hopes that the patient will not want to pursue the recommended treatment if they need to postpone by several weeks

​​​Q) What dental insurance would you recommend?

We believe dental insurance can be a great benefit when offered by employers as part of a benefits package.  But we have yet to see an individual plan that we believe is worth the cost to patients. Dental plans typically cost $40-60 per month per person, so $480 - $720 just to have the plan. And most dental plans have an annual maximum benefit for $1000-2000 each year. So the most you can hope to get out of the average dental plan, after the amount you pay to HAVE the plan, is $520 - 1200. And in years where you don’t need much more than your twice-a-year cleanings, you’ll have paid in quite a bit more than you got out of the plan.

 

We feel most patients would be better served by taking the money you'd pay to have a dental plan each month and putting it in an HSA (or even a jar). At least that way, you never pay in more than you get out - unused benefits (money) can just be saved for future years. 

 

Are there other options?

  • Yes, more and more offices are starting to offer an in-office membership plan.

    • Dr. Moses' father (who was a dentist) had one of the first in-office membership plans in the Philadelphia area back in the late-80's.

    • Dr. Moses decided to continue that plan for his patients when he and Maddy started Elevated Dental and that plan is called the Elevated Care Plan

  • ​As opposed to paying monthly premiums to a third-party insurance company, our Elevated Care Plan is a $350 annual program including 2 cleanings, 2 exams and a set of x-rays and a 10% discount on any treatment needed in that year (365 days from sign up). The only exclusions to the discount are whitening, orthodontics and sleep apnea testing & treatment. A second adult family member can be added to the plan for $300 per year and children 12 and under for $250. 

  • Even if you can find a "high-end" dental insurance plan, there is still a lot of fine print and restrictions/exclusions involved with the plan.  As an example, here is a copy of the Delta Dental Premium Plan Policy which is supposedly their “highest-end” plan:

  • And here is a copy of our Elevated Care Plan contract:

  • Now ask yourself, which contract do you think has more restrictions, exclusions, denials, limitations and surprises?  Sometimes simple is better.​​

If you feel more comfortable keeping some kind of traditional dental insurance coverage, we encourage you to look over our "What questions should I ask my insurance?" section to help ensure you are selecting coverage that works best for you and you have a good idea of what to expect!

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