A survey by Anthem “show that a lack of transparency about the cost may be what’s holding Americans back from getting preventive dental treatments, with seven in 10 people feeling that the bill at the end of the dentist appointment is more painful than the treatment. In fact, two-thirds of Americans feel like a visit to the dentist costs more than they initially expected, and this is even truer for those whose household income is under $50,000” (Malouf 2016). To provide transparency, patients can get predeterminations, which “provides a written estimate of the patient’s likely out-of-pocket expense for the care” (“Dental Benefits 101: Preauthorization versus predetermination” 2017). While predeterminations contain caveats for patients and clinics, they help patients be aware about their payments.
Predeterminations do not mean that the insurance companies will always cover the patient (“Dental Benefits 101: Preauthorization versus predetermination” 2017). In addition to estimating out-of-pocket costs, predeterminations “[provide] a confirmation that the patient is a covered enrollee of the dental plan and that the treatment planned for the patient is a covered benefit” (“Dental Benefits 101: Preauthorization versus predetermination” 2017). If the insurance company finds that the patient is not in its plan or the treatment is not covered under its plan, then it will not cover the patient. Also, when insurance companies examine dental claims, they still must consider rules, such as “limitations, exclusions, coordination of benefits and enrollee eligibility on the date of service” before providing coverage for the patient (“Dental Benefits 101: Preauthorization versus predetermination” 2017).
Predeterminations do not always mean patients will accept their treatments. According to a DentistryiQ 2013 article, “Insurance an important part of dental practice income,” says, “Studies confirm that each time a written Pre-Determination of Benefits is submitted for review, there is a 50% chance that the patient will go untreated.” Patients who receive predeterminations do not accept treatment for various reasons. For instance, a claim may not be followed up if a clinic does not monitor it or the insurance company lost it or did not get it (“Insurance an important part of dental practice income” 2013). Clinics may also wait about two to six weeks for the predeterminations, depending on the insurance company (“Dental Benefits 101: Preauthorization versus predetermination” 2017; “Pre-treatment estimates”; “Having a Major Dental Procedure? Request a Cost Estimate Before Your Appointment” 2017). Consequently, patients may “lose interest or forget about the importance of the treatment plan” (“Dental Benefits 101: Preauthorization versus predetermination” 2017). Clinics could receive predeterminations via phone and on the insurance company’s website (Weber 2015). Though, compared to a phone call, a written predetermination “may be a more accurate confirmation of eligibility” (“Dental Benefits 101: Preauthorization versus predetermination” 2017).
However, predeterminations assist patients anticipate their costs. Once patients know approximate prices “for more costly procedures such as crowns,” they can then budget their payments, encouraging them to go through these treatments (“Pre-treatment estimates”; Weber 2015). While predeterminations contain many rules, they help patients consider their costs along with their dental care.