New Billing Procedures
Thursday September 6, 2001

Dear Dr. Mady: The other day I had an appointment with my dentist and was notified that I need a crown that most likely won't be covered by my dental insurance. I was also informed that I now have to pay up front for dental work and later get direct reimbursement from my insurance company. Why can't my dentist just accept payment directly from my benefits carrier like he did in the past?
-Sam L.

Dear Sam: What you must understand is that a dental plan offered by your employer is merely meant to assist you in paying for the dental treatment that you require. The actual level of coverage that you possess will depend on what is decided by you and/or your employer or union.

When you visit your dentist, it is their duty to guide you and give you treatment options that coincide with what you actually require, not with what is covered under your benefits plan. Your individual needs may often be different from what your plan covers. You have a right to go ahead or not with any recommended treatment, but please do not make the mistake of attempting to have your dentist "treat your plan" and not YOU, or of allowing the plan to dictate the treatment.

If you consent to any dental procedures, it is your responsibility to pay on the day of service. It is the responsibility of the dental insurance carrier (a third party) to directly reimburse you for the portion of the procedure that is covered. The actual contract is between you, as the employee (and the employer) and the insurance company. Many make the mistake of believing that the contract is between the dentist and the insurance company, and this is where misunderstanding begins.

It is now recommended that dentists do not accept direct payment (assignment) from insurance companies for many reasons. Assignment causes problems because the administrative costs of filing claims and collecting partial or full reimbursement from dozens of insurance companies for hundreds of patients places a heavy financial and extremely undesirable administrative burden on a dental practice. In addition to this, many companies and plans are now sending reimbursement to the patients anyway, regardless of whether or not the claim was assigned to the dentist or not.

Ideal dental care is based on a solid relationship between the dentist and the patient, without third party interference. When the payment comes from you, the patient, there is a clear statement that our first loyalty is to you, and not the insurance company, and also it shows the dental team that you value the service that they are providing.

According to the Ontario Dental Association, these are a few good reasons why dentists should stop taking assignment:
· Dentistry has lobbied extensively to have dental services exempt from the GST, but we will now have to assume the full GST burden on dental supplies with no offsetting tax credit. This reality will add a significant burden to already escalating practice costs. Assignment is expensive and confers very little real benefit to the patient except convenience.
· Credit cards and post-dated cheques allow you at least 30 days for payment while insurance company cheques are processed within 3 to 15 days (quicker with electronic billing that many offices now offer).
· Accepting your own claims means you are taking an active interest in your own dental health and becoming a better informed consumer.
· A great number of dental patients in Ontario already collect payment directly from their insurance companies and report that prompt reimbursement is not a problem.
· Assignment is expensive and is a major contributor to practice costs, and rising dental fees and insurance premiums. Eliminating assignment will allow for savings in premiums and dental fees charged in the future.

Your dental office will usually be more than happy to contact your insurer and gain information as to exactly what is or is not a benefit, and by what percentage. They can even submit pre-determinations or estimates of required future treatment and get a response of insurance responsibility for reimbursement to the patient, prior to treatment. Keep in mind that this is usually subject to a yearly maximum benefit amount and the year does not always begin on January 1.

Ultimately it is your responsibility to understand your coverage and to pay for your dental work. If you are not covered for all necessary treatment, and if cost is a major concern, talk to your dentist and see if a payment arrangement of some sort can be negotiated. There are also many dental credit companies in existence and your dentist can advise you as to the one that best suits your situation.

I realize that dental services may appear expensive in Ontario and I do understand that we are accustomed to not paying for general health care when we visit a family physician or medical specialist. But we all have to comprehend the fact that the cost of providing health services, especially dental, is extremely high in this day and age. Overhead costs for dentists and dental specialists has sky-rocketed in recent years due to recovery from high dental education tuitions, staffing, infection control, increasing cost of supplies and overall operating costs.

My best advice is to try and avoid the need for dental work by brushing, flossing and providing yourself with excellent dental home care. Regular dental check-ups are sometimes costly but they are much cheaper than the price of correcting problems that stem from neglect.

This column is reprinted with the permission of the author and The Windsor Star. "Ask the Dentist" is written by Windsor dentist (and ECDS member), Dr. David Mady Jr.. The column appears the first Thursday of each month in the Windsor Star. Readers with questions can write to "Ask The Dentist", c/o The Windsor Star, 167 Ferry St., Windsor Ontario, N9A 4M5



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