What does “Usual and Customary” really mean?

Article reprinted from Excellence In Dentistry, LLC (1-800-337-8467)

We are often asked by our patients, “Your fee for this is over what my insurance company calls ‘usual and customary.’ Does that mean you’re overcharging me?” That’s a good question, and one we’re happy to answer.

Insurance companies, on and individual basis, come up with “usual and customary” fees for all dental procedures for a certain geographical region. When our state dental association asks theses companies for data to see how the numbers were arrived at and which, if any, dentists were surveyed, they are told categorically by your insurance company that this is confidential, internal information and they will not reveal it.

Our answer is, “If this survey was done fairly and truly represents the fees in a given area, then why can’t we see how it was done?” The insurance industry seems to be incapable of understanding this type of logic. The fact is that different insurance companies have different reasonable and customary fees for the same area. If the calculations were done correctly and fairly, they should all have the same fees. They do not because “calculations” were not done fairly and correctly.

The insurance company’s only reason for establishing artificially low “reasonable and customary” fees is to cause animosity between the dentist and the patient. It is the insurance company’s hope that the dentist will then lower his/her fees so that the company will have to pay out less money. Any time an insurance company says they want to be your friend, grab your wallet to see if it’s still there.

A dental plan is nothing more than a contract between the employer and the insurance company to partially pay for certain services. There are deductibles, some services are paid on a percentage while others may not be covered at all. Your employer buys a contract at a specified premium and includes as many or as few benefits as the employer is willing to pay for. It is a well known fact within the industry that a higher premium paid by the employer will get you, the patient, a higher “usual and customary” fee schedule.

Our fees are set by the actual costs of doing business in this particular office. Obviously, costs can vary from office to office depending on the quality of service, materials used, lab costs, and many other factors. We have never tried to be a dental office for everyone, and by the same token, we have never tried to be the cheapest office. Our fees reflect the quality of service and the care with which it was delivered. We also want our patients to know that our sterilization standards are second-to-none and are well above what is required by the profession.

If price is your only concern when choosing a dentist, then our office may not be the right one for you.