The term “usual and customary” is thrown out there a lot when it comes to dental insurance. You have probably seen the term before. “Usual and Customary” refers to a type of payment given to a dentist by your dental insurance company.
Historically, the “customary” fee has been arrived at through the use of surveys. The Insurance company contract would then specify, for example, that they would reimburse at the “80th percentile” level.
Unfortunately, with the competition between insurance companies and the pressure put on them by employers to hold down costs of policies, most insurance companies have modified the definition of the “customary” fee.
The concept of taking a survey was removed and the insurance companies are making the “customary” fee whatever they want it to be. This means that they set their own price that they will allow for every dental procedure that they cover. This is not based on what a dentist actually charges, but what the dental insurance company wishes to cover.
What is the bottom line for you as a patient? You should just be aware of some of the games that may be going on. If your dental insurance company tries to accuse your dentist of charging fees that are too high, they are being unethical.
An honest response when their reimbursement doesn’t cover the entire fee is a simple statement to the effect: “This fee is beyond the level of the allowed benefit.”
Any accusatory statements by dental insurance companies are often an attempt to cover for a plan with limited benefits that was sold to your employer as a “cost cutting” plan.
Find out more about our Houston Dental practice, at www.bridgerdds.com
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