What Good Senior Dentals Can Be Sold by Phone?

[goillini52]

I just pop in every now and again to fact check. Here are snips from a TN policy so you can see the verb-age. They do pay actual charges, however, they do limit it to R&C based on the zip code the service is provided.

POLICY YEAR DEDUCTIBLE AND MAXIMUM BENEFIT
There is a Policy Year Deductible which is shown in the Policy Schedule. After the Policy Year Deductible has been
met, benefits are limited to the Policy Year Maximum Benefit shown in the Policy Schedule.
BENEFITS
After the Policy Year Deductible is satisfied, the policy pays the following percentages of Actual Charges for Covered
Expenses up to the Policy Year Maximum Benefit:
1. 60% - first Policy Year;
2. 70% - second Policy Year; and,
3. 80% - third Policy Year, and thereafter.

DEFINITIONS
Actual Charge(s): The actual amount charged or billed, not to exceed reasonable and customary charges, for covered
medical services by a Physician or supplier.

That sounds like double talk to me.

 

[rousemark]

That sounds like double talk to me.

Duh! It is an insurance contract!..

 

[somarco]

How do they define reasonable and customary?

Do they use 100% of R&C, or 80%, or 60%?

Group America used to play games like that on their dental plans. If you had a 50% benefit based on 80% of R&C they actually paid 40% (50% of 80%). Really made life difficult for the agent that sold their plan

 

[SeanHendricks]

How do they define reasonable and customary?

Do they use 100% of R&C, or 80%, or 60%?

Group America used to play games like that on their dental plans. If you had a 50% benefit based on 80% of R&C they actually paid 40% (50% of 80%). Really made life difficult for the agent that sold their plan

They pay up to 100% of R&C at the defined coinsurance for that policy year.

 

[rousemark]

How do they define reasonable and customary?

Do they use 100% of R&C, or 80%, or 60%?

Group America used to play games like that on their dental plans. If you had a 50% benefit based on 80% of R&C they actually paid 40% (50% of 80%). Really made life difficult for the agent that sold their plan

From the way it reads, they will pay the appropriate percentage times the actual charge not to exceed the reasonable and customary charge. In other words if they are the 80% benefit level and the R&C is $100, and the dentist charges $80, they will pay $64.. However if the dentist charges $120, the most they will pay is $80 which is 80% of the R&C. Keeps the dentist from inflating his charges simply because he knows you have a plan that will pay more than R&C. .

 

[cedwards]

From the way it reads, they will pay the appropriate percentage times the actual charge not to exceed the reasonable and customary charge. In other words if they are the 80% benefit level and the R&C is $100, and the dentist charges $80, they will pay $64.. However if the dentist charges $120, the most they will pay is $80 which is 80% of the R&C. Keeps the dentist from inflating his charges simply because he knows you have a plan that will pay more than R&C. .

That's exactly right. R&C's (as long as they are not extremely low) should be explained exactly like the last sentence. If a dentist then balance bills the client, that's a whole different problem that the client should make a client evaluate how much they "like" their dentist. So far the dentist I use hasn't billed me the remaining balance after what CUL has paid. He's just glad to be getting paid for his services.

 

[somarco]

up to 100% of R&C

and how is R&C determined? Or is that considered proprietary information disclosed on a need to know basis and no one outside the carrier really needs to know.

 

[goillini52]

and how is R&C determined? Or is that considered proprietary information disclosed on a need to know basis and no one outside the carrier really needs to know.

Hmmmmmmmmmmm, the plot thickens.

 

[SeanHendricks]

and how is R&C determined? Or is that considered proprietary information disclosed on a need to know basis and no one outside the carrier really needs to know.

Believe it or not, but you can actually call or email the company and they can give you a quote by zip code on various procedures with billing codes.

 

[somarco]

Which does not answer my question.

A carrier which shall remain nameless would tell us they reimbursed in the 90th percentile based on ADA pricing codes.

Problem with that is, there is no such thing as ADA pricing codes.

I have tried for some time to find out what carriers use to determine R&C and either no one knows or they just aren't talking.