Insurance and financing can be tricky roads to navigate, and ...
there’s no easy answer to the question “Is my treatment or procedure covered?” However, you can arm yourself with information to make the road a little smoother.
Follow the guidelines here to ensure you get the most out of your insurance coverage, or help you determine the financing options that best meets your needs. An informed patient understands that your treatment plan and your financial plan go hand in hand.
For Patients with Insurance
If you have insurance, and you need to visit an oral surgeon, the first step is to contact your insurance company, and/or speak to the person responsible for benefits at your company. Here’s a list of questions you should ask before seeking treatment:
- Has your insurance coverage changed since the last time you submitted a claim (or will it change at the start of the year) and how do those changes impact you?
- If you are a new employee, when does your insurance become active and what, if any, waiting periods apply for specific procedures?
- Which practices and doctors accept your insurance?
- Does your plan allow you to go out-of-network so you can be treated by the provider of your choice?
- Are there restrictions or exclusions to your coverage that you need to be aware of?
- If you are seeking treatment for a condition diagnosed in the past, will the insurance company still cover your treatment plan?
- What out-of-pocket expenses can you expect to incur, or will you need to pay up front and wait to be reimbursed by your insurance carrier?
- Since some oral surgery procedures may be covered under medical and dental insurance, how and under which plan will your claims be billed?
Remember that the insurance contract is between the patient and the carrier, and while the doctor or practice will work with the insurance company to maximize the insurance benefits, your actual coverage will be defined and limited by the insurance carrier.
Insurance companies will never guarantee coverage for any procedure until they have processed the claim for the actual services performed. Even if the treatment plan hasn’t changed, the estimate of benefits is just that – an estimate. Your doctor recommends treatment based on the needs of the patient, but medical necessity may be defined differently by your insurance company. They make the final determination whether the treatment is covered under your policy at the time the claim is filed.
For Patients Without Insurance
If you don’t have insurance, there are other options, such as a third party financing plans or pre-tax savings plans, which can be used to cover out of pocket medical expenses.
- Third party companies, such as CareCredit, allow you to finance your medical expenses for a low or deferred interest rate, and can be used for most medical and dental expenses. Again, while your provider may work with a third party payer, the contract and payment arrangements are between the patient and the finance company.
- Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA) allow you to put a certain amount of pretax dollars aside to cover deductibles and other expenses not covered by insurance. FSA plans are administered through your employer, and HSA plans may possibly be offered through your employer. Before setting up one of these plans, make sure you understand the rules and restrictions so you know exactly how they can benefit you.
The key to ensuring you know what to expect is to be an informed consumer and patient. Asking questions, and understanding your insurance or financing plan, are the best ways to avoid unexpected out-of-pocket expenses.
The Treatment Coordinator in your oral surgery office will assist you with navigating insurance information, as well as the pre-approval and prior authorization processes; but the more you understand before you come into the office, the fewer surprises you are likely to encounter.