Insurance

Insurance

Let Gold Coast Smiles Help Navigate Your Dental Insurance



Accepted Insurance


“Do you accept my insurance?” is probably the most common question we receive at Gold Coast Smiles, and probably at any other dental office.  The SIMPLE answer to that question would be yes, to an extent.  We do work with all insurance plans as long as your specific plan allows you to visit an out of network provider.  

We are, however, only in network with Cigna PPO & Dental Premier.  Aside form these two specific plans, we are not in network with any other insurance companies or plans.  So for patients with insurance, it is very important that you make sure your plan, possibly a PPO plan, will let you go out of network and will pay out of network offices.  


We Are Here to Help


Gold Coast Smiles is a fee for service dental practice, so Patients are responsible for paying any remaining balance after their insurance has paid (or in some cases did not cover) its portion for the prescribed treatment.  Our office will submit the insurance claims for any of our patients regardless of which insurance company they have.  For patients with insurance other than Cigna PPO & Delta Dental Premier, we will help you to receive maximum ‘out-of-network’ insurance benefits for any treatment.  Our dedicated Insurance Coordinators work diligently to make sure you’re reimbursed for as much as possible under your specific plan.  After we submit the claim, the insurance company will reimburse us directly in most cases for however much they cover on the treatment you’ve received.  You will then be responsible for the remaining balance on your treatment in conjunction with any financial arrangements made prior to the start of your treatment.  

Having dental insurance, in theory, can make it easier to get the dental care you need, but very few dental plans do cover all dental procedures you might need. In fact, not only do dental insurances go to great lengths to limit what procedures they cover, they also utilize several cost-control measures in an effort to minimize their payouts when the procedure is actually covered.  These cost-control measures typically come in the form of rules, timelines and frequency limits that directly impact and interfere with the clinical judgement and the well being of patients.  They essentially handcuff the dentist from putting together a proper diagnosis and treatment plan because “the insurance won’t cover that,” leaving the patient with substandard care.  

Our decision to be a fee for service practice reflects our philosophy in patient care: Our primary goal is to help you establish and maintain quality, excellent dental health in a comfortable and modern setting.  This does not always fit into the type of insurance plan many people have, and can lead to frustration and confusion.  At Gold Coast Smiles we don’t want your treatment to be compromised by insurance rules and clauses that dictate what may or may not be allowed or how often treatment should be rendered.  Instead, we will only recommend the type of treatment that is in your best interest and maintains the current highest standard of care. 


Fee for Service Dentistry & Insurance


For anyone with dental insurance seeking our services and who’s plan allows them to come to our office, our business team is here to help you regardless of the coverage you may have.  While we don’t know exactly how much your insurance provider will pay for your specific treatment, our business team will call your insurance company, get a detailed breakdown of your dental insurance benefits, find out what they’ve paid in the past for similar services and research any inclusions or exclusions that may be present in your plan.

As with many medical providers, our fees may exceed the amount insurance carriers pay. Every dental insurance plan has different stipulations regarding access to care and payment for services rendered. Within the same insurance company, benefits may differ depending upon what type of contract employers negotiate with that carrier on an employee’s behalf.  Our business team will take the time to research all this relevant information on your behalf and create an estimate for you before treatment is started.  Benefits discussed with the patient are only estimates. In the event that a patient’s insurance carrier pays under the estimated amount, the patient will be responsible for any remaining balance.

At Gold Coast Smiles we take financial transparency with our patients very seriously and believe financial arrangements should be handled in a responsible and professional manner without any surprises to patients.   These estimates ALWAYS take place prior to the start of any treatment so patients have a clear understanding of what may or may not be covered by their dental insurance and what they will be responsible for financially later.  This allows us to further strategize and develop other financial arrangements, if necessary, to account for any costs not covered by your insurance benefits.

In addition to working with your dental insurance, here are other strategies we employ at Gold Coast Smiles to ensure that you can achieve proper treatment and keep dental costs in check.

Dental Insurance Pre-Authorizations


Before having extensive work started, our business team can contact your insurance company and submit your treatment plan to find out exactly how much will be covered.  This is almost always a more time consuming process and usually takes several weeks to be completed as we wait for your insurance carrier to process a response to our inquiry. Although this approach has the benefit of providing us with the most accurate information in confirming the type of coverage you have, it is not a suitable strategy for patients who have urgent needs and can’t risk delaying treatment and worsening conditions for several weeks while waiting for a response.  For patients that require extensive treatment but are in a more stable condition, we can utilize this strategy in putting together an accurate financial estimate and plan.

Responsible Dental Financing


If some or all of the services you want won’t be fully covered by your insurance plan, we have financing programs that can help.  Gold Coast Smiles offers responsible financing options including long term interest free financing that can help reduce the burden by giving you a small monthly payment to make instead of a large lump sum.  Click here to see our Dental Financing page.

Health Savings Accounts


Some people may be eligible to utilize other Investment vehicles such as Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA) to pay for certain dental work.  With these plans, individuals can put away pre-tax dollars into a savings account that can only go towards qualified medical procedures including some dental treatment.  Often times these plans can be administered through your employer as a benefit, and in addition to help pay for much needed dental care, they can also help you lower your taxable income.  Our business team members can help you look into these possibilities and guide you on the best way to utilize these savings vehicles towards lowering your financial burden in conjunction with other strategies mentioned above.

Invest in Your Health & Smile


Yes, certain dental services aren’t covered by basic dental insurance, but the difference they could make to your smile and your confidence levels could result in an amazing return on your investment. Certain dental procedures might even cost less than you expect. Why not set up a consultation with us at Gold Coast Smiles and find out what your options are? You might be surprised by what we can do.


Dental Insurance FAQ:


  • What is the new patient exam & does my insurance cover it?

    All of our new patient exams are meant to fully familiarize ourselves with you as a patient and your oral healthcare conditions and needs.  It started my meeting with Dr. Andrew Sami who will get to know you on a personal level and listen to your concerns and goals.  This is then followed by a thorough clinical exam and any radiographs and digital imaging that are deemed necessary.  At a minimum, we always recommend a new full set of x-rays be taken so we have an appropriate baseline to diagnose and reference back to.  CLEANINGS ARE TYPICALLY NOT COMPLETED AT THE NEW PATIENT EXAM since we use this time to exam your gums in addition to your teeth and prescribe the right type of cleaning, or other extensive gum treatment, for you.  Once the exam is complete, depending on the complexity of your case, Dr. Sami will customize a treatment plan for and present it either that same day or at a later date if further consults are required.  Financial arrangements will then be discussed and arranged with the business team prior to starting any treatment.

    Often, insurance companies cover a portion if not the entire visit.  We do not know in advance however what services (if any) YOUR insurance company will cover.  We can all guess, or estimate, based on what other patient’s insurance companies have done in the past.  All insurance companies (as well as the hundreds of different plans within each individual insurance company) vary on what they will or will not cover.  We are happy to submit claims for our patients and receive reimbursement from their insurance for the services we render.  With the exception of patients of have Cigna PPO & Delta Dental Premier, all other patients are responsible for paying for any services not covered by their insurance.

  • Do you take my insurance?

    We participate and are contracted with Cigna PPO and Delta Dental Premier and abide by their fee schedule, copays and deductibles.

    We are otherwise not listed providers with any other insurance plans and are considered out-of-network for any other plan aside from the two mentioned above.  For out-of-network patients, our office will help you to receive maximum out-of-network insurance benefits for any treatment and we will submit your insurance claims on your behalf.  Any out-of-network reimbursement we receive from your insurance will be applied towards your balance but you will ultimately be responsible for any services either partially covered or not covered at all by your insurance. We will do our best to estimate what services may or may not be covered by your insurance but there is no absolute way of knowing in advance as all insurance companies vary on what they will or will not cover.  As with all medical providers, many times our fees will exceed what your insurance company will pay.  We make sure our patients understand the cost of every procedure before we start to avoid any confusion or frustration later.

  • How do you verify my benefits?

    Upon receipt of your complete insurance information our business team will call your insurance carrier directly.  We ask your insurance carrier about your maximum, deductible, and a list of codes that are commonly used in our practice, along with any frequencies and limitations that may apply to those codes.  We prefer to speak to a live person.  However, some insurance carriers do not allow out-of-network providers to talk to representatives and in this case we request a fax of your benefits.  The fax typically does not have the specific information that we prefer, and due to the lack of information provided we may ask you to pay for 100% of services performed in our practice.

    We use the information that we gather from your insurance carrier to provide you with an itemized break down of what we estimate your carrier to cover and what we are estimating to collect from you on the date that services are rendered. The plan information that the insurance carrier gives out is never a guarantee of payment and thus every patient is responsible for the entire balance of his or her account.

  • Why isn't my treatment covered by my insurance?

    Dr. Sami diagnoses and provides treatment based on his professional judgement and expertise.  He does not let any insurance carrier dictate his standard of care.  Some employers or insurance plans exclude coverage for necessary treatment as a way to reduce their costs.  Your plan may not include this particular treatment or procedure, but Dr. Sami may deem the treatment to be necessary.  We recommend that you do not let your insurance carrier or coverage dictate your care.

  • How do I know what my patient portion, or what I owe, will be?

    The amount that we collect on the date of service will vary according to the specifics of your plan, your remaining maximum, remaining deductible, and other factors. The amount that we collect from you on the date of service is only an estimate and is based on the information that we gather from your insurance carrier. After your insurance carrier has paid for the services billed, you may be responsible for a larger portion than what we originally estimated. This is because we can only give you an estimate. Your insurance carrier has to review the claim and makes the final determination of what will be paid or denied based upon your plan guidelines and their professional determination. In turn, if your insurance carrier pays for a larger portion than we anticipate, we will refund the overpayment amount.

  • How long does it take my insurance carrier to pay the claim?

    The time for dental claims to be processed by the insurance carriers varies.  NY states has enacted laws that require insurance carriers to pay or respond to claims within 30 days.  Our practice works attentively to get your claims paid in a timely manner; however in efforts to delay payments, insurance carriers may respond to certain claims asking for further information to support the claim such as x-rays or narratives explaining why the treatment was needed.  These are typically viewed as delay tactics and will negatively impact the time it takes to receive payment.  In addition we may contact you to request additional information or in rare cases ask you to assist us in getting the claim processed.

  • Where can I find information about my specific insurance plan?

    Your Explanation of Benefits or EOB is a great place to find out information on your plan.  The EOB identifies the benefits, the amount your insurance carrier is willing to ay towards the services and what is not a covered benefit.  The statement includes the following information: UCR, copayment amount/patient portion, remaining benefits, deductibles and the paid benefits. We always encourage all of our patients to familiarize themselves with their insurance plan ahead of time to avoid confusion and frustration later.  If you ever have any questions about your EOB, our business team can help clarify things for you ahead of scheduling treatment or you can contact your insurance carrier directly.


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Gold Coast Smiles