Dear Nancy,

Why is there sometimes a balance left over when I visit the dentist? Myinsurance is supposed to pay 100%! Is there any way you can help me with this? Sincerely.

Hi, Co-Insured!

I would be more than happy to assist you with your concerns.  In my years as a dental receptionist, I have been asked this same question numerous times by people in your situation. When patients get their insurance package, whether it is individual or from their employer, they are advised that it covers a certain percentage. This percentage can vary anywhere between 50% and 100%.

When patients are told that their insurance covers 100%, they (quite understandably!) take this to mean that the insurance company will pay everything, and the patient will not have to pay anything "out of pocket".  In an ideal world, they would be right. Unfortunately, this factor of 100% depends on the fee guide your insurance plan uses (click here for an example from 2003).  The Ontario Dental Association (ODA) fee guide is the baseline that the (ODA) sets for the costs of dental procedures.  In other words, it covers the prices that every dental clinic in Ontario are advised to charge. It is important to note that this fee guide is updated every year.

With this in mind, let's return to your question. Let's say your dental office, using the 2011 fee guide, charged you $100 for a procedure. Now, if your insurance is using the 2006 fee guide, then the procedure might be listed at $90. So, even though your insurance pays 100% of the $90, it will still leave you with a balance of $10. In general, the older your plan's fee guide is, the greater your "out of pocket" payment will be.

The decision of which fee guide to use is made by your employer. For those who practice a speciality career such as a millwright or plumber, the decision would be made by your union. My suggestion would be to ask your human resources department or, alternatively, discuss your dental fee guide during your next contract negotiation.

Hopefully I have helped to answer your concerns, and if I can be of any further assistance, please do not hesitate to drop in and see me.