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Silverberg Group - Bringing Your Employee Benefits into Focus

Understanding Dental Claims

Employees that don’t understand their dental plan, often unexpectedly pay out-of-pocket for their expenses. Even worse, sometimes these employees are vulnerable to fraudulent dental claims that contribute to rising benefit premiums. With dental claims being a major pillar of most group benefit plans, it is in an employer’s best interest to ensure that their team become better dental consumers. silverteethAbout 65% to 75% of employees use their dental benefits each year. Typically, they have three to six procedures a year in one or two visits.  A typical visit is a recall exam that includes the dental trifecta of an oral exam, scaling and polishing. While every six months is generally recommended by most dental professionals, it should be noted that for a person who practices good oral hygiene, one visit per year is quite often more than sufficient. Most of this work is diagnostic and preventative to ward off cavities and ensure consistent dental health, mitigating large dental expenses and procedures at a later date. (ie. the dreaded root canal)

Unfortunately, things like overcharging and plan abuse do affect premiums. While dentists are by and large, ethical and adhere to best practices, there may be situations where procedures are performed simply because they are covered by an employees benefits plan. People have a tendency to not question their dental claims because of the client-professional relationship, but it is important that employees educate themselves to prevent unnecessary expenses for themselves and their employer.

Procedures often vary in price and if a dentist’s fees are greater than what is published in the Provincial Dental Fee Guide, or, in Alberta, what insurer’s deem to be reasonable and customary, employees may be looking at an out-of-pocket expense that is not covered by their dental plan. Additionally, deductibles and co-pay structures also may cost employees money, making dental literacy essential to cost savings. While assessing a dental claim may be difficult for a non-professional due to complex coding and invoicing, there are some key ways employers can help their team better understand their plan.

1. Refer to carriers for dental information. 

Virtually all major benefit carriers have plan websites and booklets that outline coverage and reimbursement levels. Some of the websites even allow clients to sign in and see if they are eligible for a specific procedure, and at what percentage and when. The best plan information simplifies complex jargon and plan details and may even share some of the basic codes to create better awareness of specific procedures.

2. Identify communication opportunities.

Communication is key to any employee benefits plan. If you are unsure of whether or not your employees will take the time to read a booklet or visit a website, there may be other communication opportunities available to help educate your clients and their spouses/dependents. This could include presentations or take-home videos which discuss plan information and coverage details with employees.

3. Ensure employees know their own responsibilities. 

While a co-pay program that requires a certain percentage of plan expenses to be paid by an employee will undoubtedly ensure that they think more critically about their claims, greater plan knowledge will have a similar affect and allow your team to be better consumers by making more educated and responsible decisions about where their dental plan dollars are being spent.