Insurance network change faqs

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.  

 

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

 
 
INN OON Diff Chart.JPG

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.


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.


 

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. 

 
 
 
Insurance Examples Chart.JPG
  • 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. 


 

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.


 

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.  


 

Q) What if I have potential treatment that might not be done until after December 15th?

  • Our doctors strongly believe in preventative medicine and use discretion when diagnosing treatment.  I am sure many of our patients have had a conversation with either Dr. Moses or Dr. Morgan about an area/tooth that we are putting “on watch” because we don’t believe it is quite at the point of requiring treatment.  We will follow that up with some guidance on how to hopefully prevent that area/tooth from progressing to the point of needing treatment.  That being said, we do understand that the change in our insurance network status may motivate some people to get treatment done more proactively.  If that is the case, we will offer a short re-evaluation appointment with one of our doctors at no charge.  If x-rays are needed to be taken for the re-evaluation, there will be a charge for those.  We will also increase our availability as needed to make sure we can get as many patients treated before this change goes into effect.

Q) Will my insurance company inform me of this change?

  • Yes, they will send you letters that are very biased to convince you to continue seeing an in-network provider.  Why would they do that?  When you see an in-network provider the insurance company will pay less on an annual basis which means they make more money.  Your insurance company will not readily provide OON benefits because they want to make it seem more confusing for you to see an OON provider.  We have included 2 examples we have received (below) with our comments inserted to help clarify their points.

 
 
 
 

SAMPLE Letters

 

Delta  Letter

Dear Delta Dental Member,

 

We want to inform you that your dentist, Dr. Moses will no longer participate with Delta Dental of Colorado as of XX/XX/XXXX. This means your Delta Dental benefits will no longer cover you at the same level if you continue to see this dentist after XX/XX/XXXX. Some of the most important benefits of seeing a Delta Dental participating dentist are:

-Discounted fees (true, but these fees are not reflecting rising costs)

-Delta Dental payments are sent (“assigned”) to participating dentists, so members do not need to pay “up front” for expected Delta Dental Insurance reimbursements. (we will continue just collecting estimated patient portion copays at the time of service, as we always have)

-Protection from “balance billing” (being billed the difference between Delta Dental’s discounted fees and the dentist’s regular fees) (again, the discounted fees don’t work for quality care anymore)

-Protection from “unbundling”.  This is a billing practice where one procedure is broken down and billed as multiple procedures, increasing the cost to a patient. (this is not a practice we subscribe to)

-Protection from other types of billing that can increase costs to patients. This protection can occur because participating dentists are required to honor Delta Dental claims processing policies. (the policies mentioned are inequitable and constantly favor the insurance company)

 

As a Delta Dental member, you have the freedom to visit any licensed dentist. However, you receive the greatest benefits coverage when you see a participating Delta Dental dentist. (“greatest benefit” for the patient’s health or “greatest benefit” for the insurance company’s profit?)

 

You can search for other participating Delta Dental dentists near you using “Find a Dentist” at www.deltadentalco.com 

 

When you choose a participating Delta Dental dentist, you pay less out of pocket and get more coverage. Your benefits go further. (I do love the persuasive use of “when”)

 

Cigna Letter

 

Dear <Insured Name>,

 

Starting XX/XX/XXXX, Dr. Moses, will no longer be part of the Cigna Dental DPPO  network at the following location:

 

2109 N. Frontage Rd W. Suite B  Vail, CO 81657

 

 

If you see this dentist after XX/XX/XXXX, you may pay more than if you see a network dentist. You may also have to file your own claims. (you may have to pay more because insurance reimbursements cannot support the quality of care we believe our patients deserve. And no, you will not have to file your own claims)

 

To get the most out of your Cigna Dental plan, including plan discounts and the convenience of having your dentist file your claims, you must use a XXX network dentist. 

 

Finding a new XXX network dentist (strong motivation to stay in-network because that is when they make the most profit)

 

For a current list of XXX network dentists in your area:

· Go to MyCigna.com or Cigna.com.

· Call us 24/7 at 1.800.Cigna24 (1.800.244.6224).

 

When you choose a new dentist, please call Dr. Moses to have your dental records transferred to the new dental office. If you have already started a dental treatment with Dr. Moses, you’ll

be able to finish the procedure at the network rate (if completed within 90 days from the start of the procedure). (Again, the use of “when”.  We will honor in-network fees as they state)

 

Questions or concerns?

 

We're happy to help. Please call us toll-free at 1.800.Cigna24 (1.800.244.6224). Customer Service

Advocates are available 24/7.

Q) How will my out-of-pocket costs be determined if I have OON coverage/benefits?

  • There are different “lists of fees”  that insurance companies/plans use for out-of-network vs. in-network.  We’ll try to keep this as straightforward as we can:

    • As an “in-network” provider we sign a contract agreeing to charge what the insurance company wants us to charge.  So an in-network fee for a cleaning would be $75, and when the insurance company says they will cover 100%, they are saying they will cover 100% of $75.

    • When we are an “out-of-network” provider we are not contractually obligated to charge a fee that doesn’t cover our overhead.  Now an insurance company may still say that they cover 100% of out-of-network cleanings, but they still dictate the amount they will cover up to.  

      • Honestly, I can’t blame them for capping their reimbursement considering if they covered 100% of any amount, some dentist would charge $500 for a cleaning and that would cause monthly premiums to potentially be $1000s of dollars a month.

    • For one particular insurance company, their plans either pay on UCR/R&C (Usual and Customary Rate) or at a MAC/FS (Maximum Allowable Charge/Fee Schedule).  Our out-of-network cleaning fee will be $119.  

      • For a patient who has a plan covering 100% on a UCR fee schedule, that cleaning is covered at 100% because the insurance company tells that the fee of $119 is within the covered amount.

      • For a patient from the same insurance company who has a plan covering 100% on a MAC fee schedule, that cleaning is covered at 100%, but only up to $46 because that is what the insurance caps their contribution at.  So since we are not contractually obligated to charge $46, that patient is responsible to cover the difference ($119-$46) so $73.

      • Here is this example in a chart:

 

  • One other way to convey this concept is with an equation for out-of-pocket portion:

    • MAC/FS Plan: $119 (our fee for a cleaning) - (100% coverage x $46 (“allowed” fee) = $73

    • UCR/R&C Plan: $119 - (100% x $119) = $0

    • The bold number is the crucial variable and is one that insurance companies do not make readily available.

  • Here is a chart used on Metlife’s website to help explain this subject with an example of different patients, plans and costs for a hypothetical crown. 

 

  • Moral of the story…the plan/policy that you, or your employer, have signed up for, dictates what your out-of-pocket costs will be.  If you have chosen a UCR/R&C fee schedule plan, you will get much better coverage and have reduced out-of-pocket costs.  If you have a MAC fee schedule plan, your monthly premium will be less, but your out-of-pocket costs will potentially be much higher.

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

  • Do I have OON benefits? 

    • If not, a different plan or our Elevated Care Plan would be best for you​

  • What are the coverage percentages for out-of-network providers?

    • Ideally should be 100% for Preventable, 80% for Basic, 50% for Major​

  • Do I have a deductible for preventative services (cleanings, x-rays, exams)?

    • If you do, you should ask if you can have that waived.​

  • Does my plan have a UCR or MAC/Fee Schedule reimbursement for out-of-network providers?

    • If UCR, what percentile UCR does my plan utilize? 

      • Most OON percentiles are 80-95% and should be able to increase if you would like

      • MAC/FS plans reimburse very minimally and will result in higher out-of-pocket costs

​​

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.  

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) Are there options besides dental insurance?

  • 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 $300 annual program including 2 cleanings, 2 exams and a set of x-rays and a 10% discount on any treatment.

  • 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.​​

MAC-UCR table.PNG
Metlife UCR-MAC.PNG
 
 
 
 
 
DD Premium Policy.PNG
ECP Contract.PNG