We are not a member provider with any insurance plans, however most plans provide the same benefits regardless of whether you see an in-network or out-of-network oral surgeon. Your out-of-pocket expense may be the same or only slightly different. Therefore, it is always best to choose an oral surgeon based on your dentist’s recommendations, your comfort, and confidence rather than simply on insurance membership.
Patients with insurance:
More than 90% of our patients have dental insurance although we are not a member provider with any plans. Regardless, many patients follow strict recommendations from their dentist, physician, or friends to see Dr. Kazemi because of his expertise, skills, and great office staff. Patients choose to go outside of their insurance network to get the care they want and the type of results they expect. And their insurance benefits remain the same. If you have dental insurance, you can choose to be self-reimbursed or pay only your co-payment. Our financial coordinator can help with a solution that works best for you. You can also request your insurance benefits by submitting a short form.
Difference between in- or out-of-network:
The difference between seeing an in-network and an out-of-network oral surgeon is usually insignificant. Here are the reasons why:
- Our fees are often very close to the usual and customary rates (UCR) of most insurance companies. The usual and customary rate is a fee that an insurance company allocates to a procedure in a given zip code. Because our fees and most UCRs are very close, your out-of-pocket expense may be similar or only slightly different.
- The available benefits are often the same between in- and out-of-network oral surgeons (depending on your specific plan).
- Most dental insurances offer maximum annual limits of $1,000 to $1,500 in dental benefits. Any surgical fees above this limit are not considered by your insurance, whether you see an in-network or out-of-network oral surgeon.
- Teeth extractions, anesthesia, evaluations, and X-rays are usually considered basic services with 80% coverage or in some cases as major services with 40%-60% coverage. Your out-of-pocket expense is usually insignificant between an in- and out-of-network oral surgeon.
- For the majority, the deductibles are the same between using an in-network and out-of network oral surgeon.
- Medical insurances do not offer coverage for the majority of oral surgery procedures, again, making no difference based on insurance participation.
- Many oral surgery procedures are considered elective and therefore not covered by either dental or medical insurances, regardless of whether you see an in- or out-of-network oral surgeon. These include:
- Dental implants
- Most bone grafting procedures
- Most corrective jaw surgeries
- Cosmetic procedures
Therefore, it is always best to choose an oral surgeon based on your dentist’s recommendations, your comfort, and confidence rather than simply on insurance member participation.
What does dental insurance cover?
Dental insurance often provides benefits for teeth extractions (including wisdom teeth), anesthesia, and some biopsy procedures. Simple bone-grafting procedures may be covered under some plans.
What may be considered under medical insurance?
Biopsy procedures, traumatic injuries, and some bone grafting procedures for reconstructive purposes may be considered under medical insurances. Dental implants may also be considered if tooth loss was a result of trauma or significant pathology such as cysts. Corrective jaw surgery (orthognathics) is also considered under some medical insurances although many have specific exclusions.
Procedures not covered by most insurances:
Dental implants, some bone grafting procedures, cosmetic procedures, and some corrective jaw surgeries are considered elective and therefore not likely to be covered by either dental or medical insurances. You may contact your insurance company for specific rules regarding coverage for these procedures. If you think you have possible benefits, we can assist you with submitting a pre-authorization letter and helping you obtain any available benefits.
Getting insurance for your planned oral surgery:
You may choose to get dental or medical insurance for your desired oral surgery, but make sure to inquire about specific benefits for such procedures, exclusions, and waiting periods for preexisting conditions. In most situations, insurance does little to help patients with their oral surgery cost. Insurance typically does not offer benefits for implants, bone grafting, jaw surgeries, or other elective procedures.
About deductibles, UCR’s, Annual limits, etc:
- Deductibles are fixed amounts that you must pay out-of-pocket before benefits are considered. Depending on your specific plan, this may be $50-$250 for some dental insurance or as high as $2,500 for some medical insurance companies.
- Maximal allowable, also known as usual and customary rates (UCR), refers to a fixed amount that your insurance company has allocated for a specific procedure, based on the procedure itself and zip code of the provider. For example, the maximal allowable for a tooth extraction may be $300. Your insurance company will use this amount for calculation of your benefits and may reimburse 50 to 100 percent of it based on your plan type. Any amount of the actual fee for the extraction not covered or above the maximal allowable will be your responsibility.
- Annual limits: Dental insurances have maximum annual limits for benefits. The majority are $1,000 to $1,500 per year, per individual, but may be as low as $750 or as high as $5,000 (for more premium insurance types). Any dental claims submitted are considered as long as you have available funds in your annual limit. These benefits typically expire at the end of a calendar year (usually Dec. 31st) and are not transferable.
- Percent coverage: The benefits for each procedure may be 50 to 100 percent of the UCR amount. The majority of extractions and anesthesia services are covered at 80% of the UCR. Evaluations and x-rays are often covered at 100% of the UCR. Some insurance companies limit Panorex X-rays to one every three years.