Dental insurance fee Schedules--Naperville Dentist J.A. Haselhorst for your Family Dental Care, practicing Dentistry in Naperville since 1984. Providing Cosmetic, Laser, and No Pain Modern Family Dentistry in our Modern Downtown Naperville Dental Office

I have often hear the statement, "My dentist must be overcharging me. Every time I go to the dentist I get a bill because my insurance did not fully cover my visit. My neighbors goes to a different dentist, but have the same insurance company and their visits are always fully cover by insurance." Explaining this difference is complicated and is the result of different Fee Schedules. But I will start by giving an example of situation that happen in our office.

On one day we had three patients come into our office and have the same procedure performed. The same fee was billed to each of their different insurance policies, with the same major insurance company. As it happened these three claims were settled on the same consolidated statement of benefits. For the one patient the fee was paid 100%, no amount uncovered. For the next patient the fee was paid 80%, leaving a 20% amount uncovered. For the last patient the fee was paid 50%, leaving half the fee uncovered by insurance. How is this possible? Three different policies with three very different Fee Schedules.

Fee Schedules were developed by the insurance industry as a means of restricting their liability for a given policy. These schedules place a cap or limit on the maximum amount covered for any given dental procedure. If your dentist's fee should exceed this maximum amount, the excess amount is excluded from consideration of benefits. For example if your fee schedule sets the maximum fee for a Bitewing X-ray at $15 and your dentist charges $16, then the $1 difference will not be covered by your insurance and have to be paid by you. So, you might be asking yourself, how does my insurance company determine this Fee Schedule? Good question.

There is no set rule for determining these fee schedules by the insurance industry. Each policy defines the associated fee schedules differently. There are two major factors used in computing these schedules and to provide the appearance of legitimacy. The geographic location of your dentist's practice and a percentage of fee inclusion.

Geographic locations can be divided up by cities, zip code, states, etc. Once an area is defined a survey of dental fees in the area is conducted. The dental and insurance communities have not been able to agree on how to define an area and conduct a fee survey. The dental community feels that using all five digits of zip codes to consistently define areas is best and that the survey should include all dentists practicing in the area. Insurance companies prefer using only the first three digits of zip codes to define areas and believes a sampling of dentists in the area is adequate to determine a accurate fee schedule. Although most insurance companies defines areas and sampling the same way a few do not. There is no industry standard requirement.

The percentage of fee inclusion is derived from the fee survey and becomes the Fee Schedule associate with your policy. In statistics there is something call the 'confidence interval' (sometimes called a percentile) and is expressed as a percentage. Insurance companies will describe these fee schedules using a percentage and make it sound like a confidence interval , but are careful not to use the term confidence interval. A confidence interval is calculated using the statistical average and standard deviation, and has a standardized mathematical definition. Using this calculation makes the fee schedule, for a given confidence interval, the same for all policies; the insurance companies vary the policy premium being paid by varying the percentile of the policy. This is the insurance industries primary way to limit the amount of liability for themselves.

This ambiguous nature is what lead the American Dental Association to file a class action lawsuit against a major insurance company over its using the term "Usual, Reasonable and Customary" (URC) to describe the fees listed in these fee schedules. As a result, beginning in August 2003, the insurance companies will no longer be using URC on claim settlements.

I will close with one last fee schedule story from our office. Some years ago a patient was anxious to get their fillings started and to ask me to call their insurance company and see how much of our fee would be covered. From past experience I was expecting the policy to cover around 80%. I started by asking for the policy individual maximum? $2000, on the high end, very good. What is the deductible? $25, on the low end, also very good. This policy is sounding like one of the better policies out there. I then explained that the patient wanted a filling done and told them our fee and ask: how much of it will be covered? Only 20%, major shock! I decided to ask: how much of our crown fee would be covered? 3%, I was silent, I could think of nothing to say. As the silence dragged on, the insurance customer service representative then said, "Looking at this fee schedule, they will never reach their maximum". I thanked her and hung-up. This Fee Schedule would not even cover the dental fees in a third world country, and begs the question, why have insurance? In the end the patient had around $3000 of dental treatment done and only $500 was paid for by insurance.