Insurance Information

All_PPO_Insurances_Accepted_Edward_B_Coffey_DDS_MS_Encinitas_Dental_Art

At Edward B. Coffey, DDS MS – Encinitas Dental Art we make every effort to provide you with the finest care and the most convenient financial options. To accomplish this we work hand-in-hand with you to maximize your insurance reimbursement for covered procedures. If you have any problems or questions, please ask our staff. They are well informed and up-to-date. They can be reached by phone at (760) 942-7272.

Please call if you have any questions or concerns regarding your initial visit.

Please bring your insurance information with you to the consultation so that we can expedite reimbursement.

Our Office Policy Regarding Insurance

If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay (your co-pay). By law, your insurance company is required to pay each claim within 30 days of receipt. We file all insurance claims electronically, so your insurance company will receive each claim within days of your treatment. We will wait a reasonable amount of time (approximately 4 to 6 weeks) for your insurance payment. However, after that time, we may ask that you remit any outstanding balance. We do not charge any interest on unpaid balances. We will be happy to send you a refund check when and if your insurance company does pay.

PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We will do our best to assist you in estimating your portion of the cost of treatment but we are not responsible for how your insurance company handles their claims or for what benefits they pay on a claim.

FACT 1 – NO INSURANCE PAYS 100% OF ALL PROCEDURES

Dental insurance is meant to be an aid in receiving dental care. Many patients think that their insurance pays 90%-100% of all dental fees. This is not true! Most plans only pay between 50%-80% of the average total fee. Some pay more, some pay less. The percentage paid is usually determined by how much you or your employer has paid for coverage or the type of contract your employer has set up with the insurance company.

FACT 2 – BENEFITS ARE NOT DETERMINED BY OUR OFFICE

You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (UCR) used by the company.

A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable or well above what most dentists in the area charge for certain service. This can be very misleading and simply is not accurate.

Insurance companies set their own schedules and each company uses a different set of fees they consider allowable. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then takes this data and arbitrarily chooses a level they call the “allowable” UCR fee. Frequently this data can be 3-5 years old and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit.

Unfortunately, insurance companies imply that your dentist is “overcharging” rather than say that they are “underpaying” or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary or reasonable (UCR) figure.

FACT 3 – DEDUCTIBLES & CO-PAYMENTS MUST BE CONSIDERED

When estimating dental benefits, deductibles and percentages must be considered. To illustrate, assume the fee for a service is $150.00. Assuming that the insurance company allows $150.00 as its usual and customary fee (UCR), we can figure out the benefits paid. First, a deductible (paid by you), on average $50.00, is subtracted, leaving $100.00. The plan pays 80% for this particular procedure. The insurance company will then pay 80% of $100.00, or $80.00. So, out of a $150.00 fee the insurance will pay an estimated $80.00 leaving a remaining portion of $70.00 to be paid by the patient. Of course, if the UCR is less than $150.00 or your plan pays at a lesser percent, the insurance benefit will be significantly less.

MOST IMPORTANTLY, please keep us informed of any insurance changes. Your insurance company name, claim submitting mailing address, phone number and group number MUST be provided to us by YOU. Our software requires the name of the insured, their date of birth and social security number along with the patient’s date of birth and social security number (minors are exception to SS#). Most insurance companies are changing from the SS# to some other identification # and hopefully our software will update to accept this alternative # soon.

We accept ALL PPO insurance plans as an out-of-network provider.

Our office is in-network with the following dental plans ONLY:

  • Aetna PPO
  • Delta Dental (Premier plan)
  • Cigna PPO