Insurance estimates vary according to insurance companies and plans. Different plans may produce different estimates for the same procedure. Data on the benefits an insurance company pays for a specific procedure is kept current by updating the blue book.
A doctor might negotiate an agreement with one or more insurers to provide dental services at a usual, customary, and reasonable (UCR) rate, which is not necessarily the same as the doctor’s fee schedule. The insurer agrees to pay some or all of the UCR amount, which is expressed as a flat rate or as a percentage.
The agreement between the insurer and the doctor specifies whether the doctor can charge the patient for the amount in excess of the UCR.
A doctor and an insurer might enter into a particular type of agreement called a capitation plan, which pays the doctor a fixed amount for each of the insurer’s customers who enroll with the dentist. The fee is paid to the doctor monthly, whether dental services are provided or not. If a patient requires dental services, the patient pays nothing or pays a co-payment.
Other factors include primary and secondary coverage, yearly deductibles, lifetime limits, and so on.
A dental office provides a service to the patient by providing an estimate and informing a patient how much he or she owes.
Note: If a dentist’s fee is less than the insurance company’s UCR, the company bases its insurance calculation on the dentist’s fee. If a dentist’s fee is less than the insurance company’s UCR, the company bases its insurance calculation on the dentist’s fee.
Methods of Estimating Insurance
Code-Specific Estimating by Plan
Benefit-Table Estimating by Plan
Copying Code-Specific Estimating Information