"Reasonable and Customary" What Does It Mean?
We are often asked by our patients, "your fee for this is over what my insurance company calls 'usual and customary', does that mean that you are overcharging me?" That is a good question and one we're happy to answer.
Insurance companies on an individual basis come up to the "usual and customary" fee for all dental procedures for a certain geographical region. When our state dental association asks these companies for data to see how the numbers were arrived at and who, if any, dentists were surveyed, they are told categorically by every insurance company that this is confidential, internal information and they will not reveal it.
Our answer is "If this survey was done fairly, and truly represents the fees in a given area, then why can't we see how it was done?" The insurance industry seems to be incapable of understanding this type of logic. The fact is that different insurance companies have different reasonable and customary fees for the same area. If the calculations were done correctly and fairly, they should all have the same fees. They do not, because the calculations were not done correctly and fairly. The insurance company's only reason for establishing artificially low "reasonable and customary" fees is to cause animosity between the dentist and the patient. It is the insurance company's hope that the dentist will then lower his fees so that the company will have to pay out less money. Any time an insurance company says they're on your side, grab your wallet to see if it's still there.
A dental plan is nothing more than a contract between the employer and the insurance company to partly pay for certain services. There are deductibles, some services are paid on a percentage while others may not be covered at all. Your employer buys a contract at a specified premium and includes as many or as few benefits as the employer is willing to pay for. It is a well known fact within the industry that a higher premium paid by the employer will get you, the patient, a higher "usual and customary" fee schedule.
Our fees are set by the actual costs of doing business in this particular office. Obviously, costs can vary from office to office depending on the quality of service, materials used, lab costs, and many other factors. We have never tried to be a dental office for everyone, and by the same token, we have never tried to be the cheapest office. Our fees reflect the quality of service and the care with which we give each and every patient. We also want our patients to know that our sterilization standards are second to none.
If price is your only concern when choosing a dentist then our office may not be the right one for you.
"How come you're not on the list of dentists my company wants me to go to?"
This is a question we are often asked by our patients when their company switches to an HMO or PPO dental plan, and we hope to clear up much confusion by answering it.
Every dentist is solicitated by three or four insurance companies a month to join their family of HMO/PPO dentists. Contrary to popular belief, there is no quality control or screening process to select top dentists in the area. In fact, the insurance companies make no evaluation or assessment of a dentist's clinical skills whatsoever. Basically, the only two requirements I've ever seen to sign up as a HMO/PPO provider is 1) do you have a license to practice and 2) do you have a heartbeat.
The promotional material provided to you the patient by this multi-billion dollar insurance company is very appealing. It makes it sound like you've just hit the lotto and there really is a free lunch, or so it seems that way. It appears that every one wins in the deal, you, the patient, now get free ( or greatly reduced ) cleanings, x-rays, exams and perhaps even fillings. Even the major treatment is much cheaper ---- you're ecstatic. The upper management of your employer has a much cheaper dental insurance premium to pay each and every month ----- they're ecstatic. If you have been following the profits of these HMO companies, you are aware that they are making money hand over fist. The insurance company executives are among the highest paid in the business world ---- they're more than ecstatic, they're doing handstands to work!
So who is the loser here? Everyone seems to be getting more for less, this must be the mystical free lunch at last. Unfortunately it isn't. There has to be someone absorbing the costs of all this free, cheaper treatment. You may have already guessed it, it's the HMO/PPO dentist. Now you ask,
"Why would anyone want to work harder for less money?"
Well ladies and gentlemen, that is the $64 Question we in the profession have asked ourselves. Let's look at why anyone would do this.
Like Lucifer, the insurance industry dazzles the prospective dentists with promises of wealth, endless patients, busy practices, happy patients, and then they add, "Oh did we mention that you will have to give away many services for free, and cut the rest of your fees by 30-40%?"
"But don't worry about that", they quickly point out, "because you will have two to four times as many patients to try and see in order to make up for the lost revenue. You'll just have to work faster".
To many financially struggling or marginally proficient dentists, the temptation is too great and they sign up only to quickly realize that their life and soul now belongs to these insurance companies.
Understand that as a HMO/PPO provider, the dentist is paid say $10 per month per family or patient, whether or not that patient ever shows up in the office. Now if the patient does want to show up and get their teeth cleaned or a filling done for example, ( which the dentist may have to do for free ), do you think that the dentist actually wants to see that patient. Of course not, the dentist does not make any money when a patient comes to the office!
This is the game the HMO/PPO provider has to play with you, the patient, in order to stay in business. Now you see why it might be difficult for you to be seen for a routine visit or in an emergency. The biggest complaints from patients with an HMO/PPO plan is that they can't get an appointment or they never see the same dentist twice. This also happens in medicine and with your physician. Have you ever had a test scheduled that was changed or canceled because of insurance coverage. Or a hospital stay shortened unnecessarily? This is the insurance game! Is it any mystery now why that is the case?.
In my opinion to be a HMO/PPO provider dentist, I would be forced to sacrifice quality, service and the personal attention that I give to all of my patients. In short I would be forced to give up my ethical standards of care. I refuse to do that and I will not. That is an easy choice and the only right one for me to make. I do not want to practice lowering my quality of care, using cheap materials, cheap labs, cutting corners etc. Many corners could be cut in the area of sterilization alone by not using so many disposables and procedures to protect you, the patient. I will not have an insurance company telling me what is right for you or what treatment is needed for you as the patient.
The medical profession has all but lost the war to the insurance industry. This story has been well documented in magazines and the news often. I am sure you already have experienced some form of this already. The dental profession in this area, still has, by and large, the freedom of choice. As long as that continues, I will endeavor to provide you with the best that dentistry has to offer.