Did You Know: Dental PPO Balanced Billing?

Dental Benefits: What is Balanced Billing? 

 

 

This year, once a month, Council Services Plus will be bringing you tid-bits of helpful and interesting facts and information about insurance. 

  

Last month we discussed Dental Benefit Maximums; so keeping with that theme, this month we

we'll focus on another term that often is associated with dental benefits: PPO Balanced Billing.

Many times employees choose a dentist that may not participate in the "network" of dentists approved by the plan offered by the employer. Many dental plans offer out-of-network benefits and still pay claims submitted by dentists that do not participate with that plan. If your plan has out-of-network coverage (usually associated with Point of Service (POS) or Preferred Provider organization (PPO) plans) you need to be aware of the fees charged by that dentist, and what your plan deems as reasonable and customary (R&C) charges that they will pay for.

When you use a participating (or preferred) provider, that dentist has agreed to accept the company's R&C fees as the basis for their billing. For example, if a filling R&C fee is $100, then the participating dentist must charge that for a filling. If your coinsurance is 80%, then you pay $20 (20% of $100) and the company pays $80.

 

Let's now assume you go to a non-participating provider and they charge $150 for the same filling. The insurance plan will still base the amount they pay at 80% of R&C ($100) and you must pay the "balance" of the bill due to the non-participating dentist. Under this situation, your cost is $70 ($150-$80). You can see why you may "prefer" to see a "preferred" provider in a PPO plan to help keep your costs down.