Scenario #1: A 10 year old girl complains of frequent headaches and when it begins to interfere with attendance at school, her parents take her to the doctor. After accessing the child, the doctor states he needs an x-ray for a more decisive diagnosis. The parents agree. The doctor finds a tumor and reports that luckily it is early and very small and feels with immediate treatment, there will be a positive outcome although unsure if his treatment will be covered by insurance. The parents tell the doctor to do whatever is needed.
Scenario #2: A 10 year old girl complains of frequent jaw pain and when it begins to interfere with attendance at school, her parents take her to the dentist. After accessing the child, the dentist states he needs an x-ray for a more decisive diagnosis. The parents disagree stating that x-rays are not covered under their dental plan. The dentist is concerned for the child and so takes an x-ray at no charge and finds decay, but luckily it is small and feels if treated immediately, there will be a positive outcome. The parents feel that since it is small, they can put this off for a few months as they have vacation plans and can’t afford this right now as their current dental insurance will not cover the procedure. While on vacation, the child wakes up in pain, this time with a swollen jaw. They take her to the emergency room and find the tooth is abscessed and she needs to be put on an antibiotic. Another x-ray is taken only to find that the decay spread and the root is now involved and the child now needs a root canal or she will lose the tooth.
It is a mistake to let benefits be your sole consideration when you make decisions about dental treatment. People who have lost their teeth often say that they would pay any amount of money to get them back. Your smiles, facial attractiveness, ability to chew and enjoy food, total body wellness and general sense of well-being are dependent upon your teeth.
Understanding your dental benefits is not easy. There are many different plans as there are contracts. Your employer has selected your plan and is ultimately responsible for how your contract is designed. It is important to know that each contract will specify what types of procedures are considered for benefits. Even if a procedure is medically or dentally necessary, it may be excluded from your contract. This does not mean that you do not need the procedure. It simply means that your plan will not consider the procedure for payment.
Here are answers to a few common questions regarding dental insurance:
Why doesn’t my insurance cover all costs for my dental treatment?
Dental insurance isn’t really insurance (a payment to cover the cost of a loss) at all. It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost.
But my plan says that my exams and other procedures are covered at 100%!
That 100% is usually what the insurance carrier allows as payment toward a procedure, not what your dentist or any other dentist in your area may actually charge. The allowed payments are sometimes referred to as UCR or “usual, customary, and reasonable” charges. However, UCR more typically represents a list of payment amounts negotiated between your employer and the insurance company. An employer usually selects a plan with a list of payments that corresponds to its desired premium cost per month. Therefore, there usually will be a portion not covered by your benefit plan.
I received an “Explanation of Benefits” from my insurance carrier that says my dental bill exceeded the “usual and customary”. Does this mean that my dentist is charging more than he/she should?
Remember that what the insurance carriers call “usual and customary” is really just what your employer and the insurance company have negotiated as the amount that will be “allowed” as payment toward your treatment. It is usually always less or even much less than what any dentist in your area might actually charge for a dental procedure. It does not mean that your dentist is charging too much.
If I always have to pay out-of-pocket, what good is my insurance?
Even a benefit that does not cover a large portion of the cost of what you need pays something. Any amount that reduces your out-of-pocket expense helps.
Why is there an annual maximum on what my plan will pay?
Maximums limit what a carrier has to cover each year. Dental plans are different from medical plans, in that dentistry is needed frequently. Medical emergencies are rare. It is your dentist’s responsibility to recommend what you need. It is the insurance carrier’s job to control payments.
What should I do if my insurance doesn’t pay for treatment I think should be covered?
Dentists do not have the power to make your plan pay. If your insurance doesn’t pay, you are responsible for the total cost of treatment. Sometimes a plan will pay if patients send in claims for themselves, or if the Employee Benefits Coordinator where patients work steps in.
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With Oshins of Smiles, Dr. Oshins
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Dr. Steven Oshins is committed to achieving extra-ordinary levels, expanding both knowledge and application skills in restorative dentistry in order to provide his patients with the highest standard of care. He is not here to judge patients, but to thoroughly learn about each patient’s oral condition, determine their susceptibility to future breakdown, and discuss a plan to help them successfully achieve and maintain a healthy and attractive smile.
A lifelong capital district resident, Dr. Oshins graduated from the University at Buffalo School of Dental Medicine. He pursued his childhood dream of becoming a dentist because it combined his love of science and technology and the visual arts with his overwhelming passion to help people. While in dental school, he was one of two students across the United States selected for an internship at the Unites States Penitentiary, Atlanta Dental Clinic, where he worked under the most prestigious dentists in the Federal Government.
Upon graduation, he completed his two-year residency at Ellis Medicine in Schenectady, NY. During his second year of residency, he worked with various local oncologists and cardiologists and developed protocols for patients prior to starting chemotherapy, radiation treatment, or cardiac surgery. He stayed on as a staff dentist until 2000, when he opened up his private practice in Guilderland, NY. Dedicated to providing his patients with the most effective, up-to-date, and proven dental treatments, techniques, and options, he pursued multiple post-graduate programs in advanced dentistry, studying under the top dentists in the world, such as Dr. John Kois, Dr. Frank Spear, Dr. John West, and Dr. Ronald Jackson, completing over one hundred continuing education hours each year. He recently graduated from the renowned Kois Center, an advanced didactic and clinical program for practicing dentists, after completing a comprehensive, rigorous nine course curriculum with the latest advances in esthetic, occlusion, implant, and restorative dentistry.
Because of his compassion for others, he donates his personal time and professional services to local schools and humanitarian organizations, such as Habitat for Humanity and Freihofer Run for Women. He taught radiology and worked in the clinic for eight years at Hudson Valley Community College in the Dental Hygiene program and has a current faculty position at Ellis Hospital Residency program. He also writes a monthly article for the Guilderland Our Towne newspaper in hopes of sharing his knowledge of how to achieve lifelong oral health. He hopes to realize his dream of participating in missions to impoverished countries to teach proper oral health and provide services to the needy.
He is a current member of the American Dental Association, New Your State Dental Society, Western New York Kois Study Group, Third District Society, Ellis Medicine Implant Study Club, and Guilderland Chamber of Commerce.
In his spare time, Dr. Oshins enjoys spending time with friends and family, especially with his aunt and uncle at their camp in Lapland Lake, NY. A standout soccer player in high school, he continues his love of the sport by playing in local recreational leagues. He also enjoys all sports, working out, traveling, biking, kayaking, photography, and the arts. He continues his passion for cooking and takes classes at the Culinary Institute of America and Schenectady Community College.
Dr. Oshins’ greatest achievement is the difference he makes in his patients’ lives by helping them smile.