Usual and Customary

on November 20, 2013

Continuing along with our insurance tips and definitions, today we will explore an insurance term called “usual and customary.”

As we discussed last week, dental insurance plans usually have different breakdowns of coverage. These are paid out at differing percentages, but percentages of what? Contrary to what most people believe, it is not a percentage of the dentist’s fees. Instead, it is a percentage of an allowed amount that the insurance company has set. This allowed amount is known as the insurance company’s usual and customary fee.

Insurance companies use different surveys to determine the usual and customary fee. These fees may be higher or lower than the dentists in your area. An insurance company may use a survey of dentists across the nation; across the Midwest; across Illinois, or across Evanston. Different surveys will result in a different usual and customary fee. When you visit an out-of-network provider, the insurance company pays the percentage of the usual and customary fee and the patient is responsible for the remaining percentage as well as the difference between the two fees.

An example would be a prophylaxis (cleaning) that is covered at 90% by the insurance company. Let’s say that the dentist charges $100 for a prophylaxis, but the insurance company’s usual and customary fee is $90. This means that the insurance company will cover 90% of $90, which is $81. The patient is responsible for the remaining $19 – $9 from the 10% the insurance didn’t cover of their usual and customary fee and the $10 difference between usual and customary and the doctor’s fee. Here is how the breakdown may look on an insurance form:

If this isn’t crazy enough, just wait! Check back with your friendly neighborhood Evanston dental office next week, when we bring deductibles into the mix. As you can see, insurance coverage can be a bit elaborate. The most accurate answer you can get as to what and how much your insurance company will cover is by asking them. So until next week, keep smiling and flossing.

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