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Dental insurance companies (unless they are DMOs) often use the term "usual, customary and reasonable" (UCR) when discussing fees charged for dental care. When you receive a statement of the claims paid for your treatment by the particular company that your employer has engaged to provide you with dental benefits, it may state that one or more of the fees in question are above UCR. The clear suggestion is that the fees you were charged are too high.
But, too high according to whom or what?
The insurance companies that sell dental plans to employers such as yours each determine UCR fees for a given area individually. If you were to ask any of these companies (including the one that covers you) how they establish their UCR fees, they will tell you it is none of your business. If you were to ask what communities make up your area or how many and which dentists were surveyed in determining UCR, as the Illinois State Dental Society has done repeatedly over the years, you would be told the same thing. Don't you think it odd that factors which directly affect your ability to obtain health care should be none of your business? If the insurance companies set UCR fees fairly, why won't they disclose how they do this?
Dr. Roden sincerely believes that the reason for this is that when insurance companies use the term "usual, customary and reasonable" what they really mean is the least possible expenditure they can get away with. Remember, a dental plan is nothing more than a contract between your employer and an insurance company to pay for some of what your dental needs cost in any single year. To gain the most profit from this contract, insurance companies can do only two things. They can raise the price of their coverage by increasing premiums or they can devise ways of reducing what they will pay out in coverage. Since most employers are primarily concerned with what dental benefits cost them (profits are what your employer is in business for), it is easier for insurance companies to reduce benefit payments than to raise premiums. They achieve these reductions in many ways including high deductibles, long waiting periods before covering some types of standard treatment, not covering other types of standard treatment at all, excluding treatment of situations that existed before you were covered (pre-existing conditions) or treatment they consider "experimental", low percentages of coverage and the artificially low fixing of their UCR fees. In this last way of reducing benefits, the insurance company blames the dentist for any shortfall in coverage without admitting to their own profit motive. It should not come as a surprise to you then that different plans from the same insurance company covering the same area can have different UCR fee rates depending on how much an employer is willing to pay for the plan.
The fees we charge here in the office are set according to what it costs us to offer the level of service we work very hard to provide for you. These costs will vary from office to office, but ours reflect the caliber of dental laboratories we use, the techniques we employ and the materials we utilize in trying to do the best that we can for you. They also reflect the concern we have for the well-being of every person who entrusts us with their care. We believe these attributes go beyond what fees alone stand for and we hope that you perceive the value in how we look after each and every patient. If the price of dental care is your only concern in choosing a dentist, our office may not be the right choice for you.
As the noted dental benefit analyst Tom Limoli, Jr. wrote in the October 2004 issue of Dental Economics (and is still very true today):
"Parameters of care are very different. Many say they should not be confused with or influenced by a benefit plan's parameters of payment. This two-lane road moves in both directions as parameters of payment should not govern or direct parameters of care. Why? A benefit plan's parameters of payment are influenced primarily by the strength of the plan purchaser's almighty dollar. The more the purchaser pays for a plan, the richer the benefits available to the enrollees. High dollar plans have higher dollar benefits. Conversely, low dollar plans don't have a whole lot of covered benefits." In this case, the "purchaser" is your employer and you are the "enrollee".
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