• Lindi J. Ezekowitz, D.D.S.
  • Rosalyn M. Sulyanto, D.M.D., MS

7 Graf Road
Suite 2A
Newburyport, MA 01950

(978) 462-2227

Financial and Insurance

Your treatment plan estimate will include a breakdown of all applicable fees and we will inform you of all predicted costs before treatment is administered.

Payments are due at the time of treatment. For your convenience, we accept cash, check, Visa, MasterCard, AMEX, and CareCredit. Prior arrangements need to be made for payments if someone other than the parent/guardian brings your child for an appointment.

We are a provider for Blue Cross Blue Shield, Delta Dental Premier, and Altus Insurance. We will submit insurance claims for you. We will make every effort to help you receive full insurance benefits but please remember that dental insurance is meant to provide assistance with the investment in your family’s dental health and is not meant to pay full fees.

PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company and we cannot be responsible for how your insurance company manages claims or for how they pay benefits on a claim. We can only assist you in estimating your portion of the cost of treatment. Unfortunately we cannot always predict how your insurance company will handle your claim.

No Insurance Pays 100% of All Procedures

Dental insurance is meant to a be a benefit to aid in receiving and paying for dental care. Many patients think that their insurance pays 90%-100% of all dental fees whereas most plans realistically pay between 50%-80% of the average total fee. Some insurance plans pay more and some companies pay less. The percentage that your insurance company will pay is usually determined by the type of contract your employer has set up with the insurance company.

Benefits are not Determined by our Office

girl_W_purse You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee. Frequently insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (“UCR”) used  by the company. A statement such as this one gives the impression that any fee greater than the UCR fee is unreasonable or well above what most dentists in the area charge for a certain service.

Recall that the UCR fee is a number that is chosen by the different insurance companies and is at the discretion of the insurance companies; the UCR fee does not necessarily reflect the “appropriate” cost for a specific procedure. Note that even though insurance companies often set their own UCR fees, insurance companies usually pay only a set PERCENTAGE of their set UCR fee, and NOT THE FULL UCR fee.

Frequently the data used by the insurance companies to determine their specific UCR fees can be three to five years old, and these “allowable” fees are set by the insurance company so they can make a net 20%-30% profit.

Some patients misinterpret an insurance company’s relatively low UCR fee as implying that your dentist is “overcharging” rather than thinking that the insurance company is “underpaying.” In general, a less expensive insurance policy will use a lower UCR figure.

Deductibles and Co-Payments Must be Considered

When estimating dental benefits, deductibles and percentages must be considered. Some factors that may affect the amount of insurance company reimbursement, other than deductibles, and thereby the patient’s financial responsibility include:

  • If the UCR fee is not equal to the dentist’s fee
  • If the insurance plan pays only a percentage of the UCR fee
  • If the yearly maximum benefit has been met
  • If the procedure is not covered

EXAMPLE 1:

Assume the fee for a particular service is $150.00 and the insurance company allows $150.00 as its UCR fee. If a particular plan pays for 80% of the UCR then the patient is responsible for $30.00 and the insurance company will pay $120.00.

$150 fee – Insurance Reimbursement = Patient Responsibility
$150 fee – (80% reimbursement of UCR of $150) =
$150 fee – ($120 paid by insurance) = $30 patient responsiblity.

If there is a deductible, one may be responsible for an additional $50 (on average) making the patient’s contribution $80.00 and the insurance company’s contribution $70.00.

EXAMPLE 1 WITH A $50 DECUCTIBLE:

$150 fee – Insurance Reimbursement = Patient Responsibility
$150 fee – ($120 normally paid by insurance – $50 deductible) =
$150 fee – ($70 paid by insurance) = $80 patient responsibility

EXAMPLE 2:

In this example the dentist’s fee for the procedure is $150 and the insurance company’s UCR fee is $100. Here, the insurance company pays 80% of the UCR fee:

$150 fee – Insurance Reimbursement = Patient Responsibility
$150 fee – (80% insurace payment of UCR fee of $100) =
$150 fee – ($80 paid by insurance) = $70 patient responsibility

Notice that in this situation, the $100 UCR fee set by the insurance company is less than the dentist’s fee of $150, and that the insurance company only pays 80% of its set UCR fee.

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