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  • Writer's pictureBuffalo Dental Implant

GHI/Emblem Preferred, Spectrum and M has Balance Billing. What does balance billing mean in dental insurance?


Understanding Balance Billing for Dental Insurance

Emblem writes, "EmblemHealth does allow its participating network dentists in existing Preferred, Spectrum and M programs to balance bill the difference between office charges and the EmblemHealth allowance when any higher quality materials are used." This policy applies to  Fillings for molars, Crowns, Pontics, Abutment Crowns, Onlays and Flexible dentures.

But what does balance billing mean? It means that for those procedures, Emblem pays a part of the cost and then the patient gets billed for the remainder of the fee.

Isn't this like a co-pay? Not really. For most dental procedures, your insurance determines how much each participating dental office can charge for each procedure. So for example, they may determine that an exam is $60 and they will pay 50%, 80%, 90% or 100% of the exam. When they pay less than 100%, then the patient is responsible for the remaining percentage. That is a co-pay.

Balance billing means that the insurance company determines how much the crown will be and what they pay towards it, but each dentist office can use their own fees instead of fees that the insurance company sets.

So for instance with these plans, insurance has determined that a crown is $200 and that the dentist office can balance bill. Insurance will then pay 50%, 80%, 90% or 100% of the crown up to their $200 determination. The dental office then can balance bill the patient up to what ever their office self pay rate is. So if our office charges $300 for a crown, we can bill the patient for the remaining $100. This is because most dental offices use higher quality materials that the insurance determines is adequate.

Example - fillings for molars. Emblem pays for amalgam fillings for the molars because they say that no one will see fillings that far back in the mouth and silver fillings would be fine. They determine that white filling material is cosmetic and not necessary. Many offices (like ours) don't use silver fillings anymore. So to prevent us from losing money on all fillings, they allow us to balance bill for the difference. This prevents dentist offices from dropping that insurance, and then that insurance becomes less valuable to their covered patients. In an ideal world, insurance brings value to a dental office and the dental office brings value to the insurance company and their participants.

As a plan participant, it's important that you are told about balance billing before the procedure is done. The insurance companies strongly urge each dentist office to put this policy in writing and have you sign as proof that you were told. We agree. No one likes surprises at the end.

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