Does the Insurance Company control what the Dentist charges?

Oct 28, 2014
According to the BCDA, 62 % of Canadians were covered by dental plans in 2010. These plans are a valuable financial resource to plan members, but who actually controls the costs.
The policyholder (employer or plan sponsor) will set all of the various provisions of the plan which outline what is covered and in to what degree those services are covered. The plan provisions will detail elements such as deductibles, coinsurance, maximum benefit levels and limitations. Depending on how the plan sponsor designs the plan, plan members may still be required to pay for a portion of the cost of dental care and often wonder if they are being charged appropriately for services that the plan doesn’t cover.
The insurance company insuring the dental coverage on behalf of the employer, will adjudicate claims based on the provisions of the coverage selected by the employer and pay claims up to the ‘reasonable and customary’ amount for a recommended procedure and most often according the Provincial Dental Fee Guide established each year by the Dental Associations in each province.
Your dentist is a highly trained professional and responsible for delivering the most appropriate level of care for your dental health. They won’t make recommendations based on the terms of your employer’s dental plan so you should always ask for an estimate and have your dentist seek preapproval from the insurance company. Any portion of the cost not covered by the plan will be known in advance and you will have an opportunity to discuss your dental care more directly with your dentist before any procedures are started.
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