Truth: Insurance may not pay 100% of hygiene visits.

Most insurance companies state that they will cover two hygiene visits a year—either once every 6 months or twice a year, anytime.

But in small print, the plan document might say something like this: We will pay 100% of dental hygiene fees that we deem reasonable and customary.

So if your hygiene fee falls in the reasonable and customary range, the company will pay 100%. If the fee is outside this amount, insurance will pay a smaller percentage. Then the patient is responsible for the amount unpaid by insurance.

The policies small print may cause confusion for dental patients. Often insurance companies refuse to raise fees paid (even when increasing premium amounts). In fact, the largest dental carrier that covers South Carolina state employees still pays the same amount it paid in 1970.

Obviously, dental offices have raised fees since 1970. And patients want a thorough and complete exam rather than a “reduced fee exam.”

Truth: Insurance company sets Reasonable and Customary fee for your employer to keep premium costs low.

The insurance company will negotiate an “allowable amount” or “usual and customary fee” with your employer. This will help determine the premium amounts that your employer pays.

This amount is usually less than what any dentist in your area charges. It is beneficial for the insurance company but not necessarily reasonable for dentists in your zip code area.

If your dentist’s fee is higher than the set fee, this does not mean your dentist is charging too much for a procedure. Instead, it indicates that the employer used low fees to negotiate lower premiums for your company plan. Or that the insurance company did not raise the reasonable amount for many years.

Your insurance company will apply the negotiated percentage for each procedure based on the employer contract.