Financials in Ontario

Insurance

Not all insurance plans are the same, so it’s essential to bring a copy of your insurance card or paperwork when visiting our office for the first time. This information can be scanned into the office system and used for future billing.

• We submit claims electronically to most insurers on your behalf.
• Where your plan allows assignment, we can bill the insurer directly so you pay only your portion.
• For treatment of any size, we recommend a pre-determination. The plan is sent to your insurer first and they confirm in writing what they will cover.
• Bring your policy and plan numbers to your appointment, and tell us if they have changed.

What a plan covers is a contract between you and your insurer, and we cannot change its terms. Annual maximums, waiting periods, frequency limits on cleanings and exclusions on major work are all common. Knowing yours before you plan treatment avoids unwelcome surprises. A pre-determination is the reliable way to find out.

Payment Plans

This is an excellent option for patients who need more in-depth care, such as root canals or orthodontic procedures that last a long time.

How we handle cost

Nobody should find out what treatment costs after it has been done. For anything beyond a routine examination and cleaning, you get a written treatment plan listing each item, its fee code and its cost, before anything goes ahead. You can take it away, check it with your insurer, and decide in your own time.

Ontario dentists set their own fees. Most use the Ontario Dental Association's Suggested Fee Guide, which is published annually, as a reference point. The fee codes on your plan are the standard ones insurers recognise, which is what makes a pre-determination possible.

The Canadian Dental Care Plan

We are a participating CDCP provider and can bill the plan directly. The CDCP pays a share based on your income tier and pays at CDCP rates, so a balance is sometimes payable. We will tell you the amount before treatment. Eligibility is decided by the federal government, apply through Canada.ca.

Direct billing, and what it does not mean

Direct billing means we submit your claim to the insurer and, where your plan permits assignment, receive their portion directly so you pay only the balance. It saves you paying the full amount up front and waiting for reimbursement.

What it does not mean is that the insurer has agreed to pay. Submission is not approval. A claim can come back reduced or declined for reasons that have nothing to do with the treatment — a maximum already reached, a frequency limit, a waiting period, or a plan detail neither of us could see. Where that happens the balance is yours, which is the honest position and the reason we recommend a pre-determination for anything substantial.

Not every plan allows assignment. Some require the member to be reimbursed directly, in which case you pay us and the insurer pays you. Your plan documents will say which applies, and it is worth knowing before a large appointment.

What makes one treatment cost more than another

Dental fees can look arbitrary from the outside. They are not, the number generally tracks four things, and knowing which one is driving a quote makes it much easier to compare options.

• Chair time. A filling is one appointment; a crown is two, with laboratory work between them; an implant runs over months. Time is the largest single component of most fees.
• Laboratory costs. Crowns, bridges, dentures and night guards are made by a dental laboratory, and that cost is passed through. It is a real external cost rather than a margin.
• Materials. Zirconia, gold and composite differ in price, and so do implant components. Where there is a meaningful choice, we will tell you what the difference buys you.
• Complexity. An impacted wisdom tooth close to a nerve is a different procedure from a straightforward extraction, even though both are "taking a tooth out".

This is also why a quote given over the phone, before anyone has looked at the tooth or an X-ray, is not worth much. The examination is what establishes which of these apply.

Understanding your treatment plan

Dental treatment plans use standard procedure codes, the same ones insurers use. That is deliberate. It means the plan we hand you is the document your insurer can price, and you are not relying on anyone's description of what was proposed.

A plan will usually group work into phases. Urgent items, pain, active infection, a tooth at risk of fracturing, come first. Then the work that stops problems getting worse. Then anything elective. That order exists so that if you need to spread treatment over time, the sequence still makes clinical sense rather than leaving something urgent until last.

Ask us to explain any item you do not recognise. It is a reasonable question and the answer should be a plain-language description of what the code covers, not the code read back to you.

Questions worth asking your insurer

Most unpleasant surprises come from plan terms rather than from fees. Before committing to substantial treatment, it is worth confirming five things with your insurer directly:

• Annual maximum, the ceiling on what the plan will pay in a benefit year, and how much of it you have already used.
• When the benefit year resets. It is often not January. Timing treatment across a reset can meaningfully change what you pay.
• Frequency limits, how often cleanings, examinations and X-rays are covered. Nine months is a common interval even where the plan says twice yearly.
• Waiting periods On major work, which are common in the first year of a new policy.
• Coordination of benefits, if you are covered under two plans. Together they may cover more than either alone, and the order of submission matters.

If cost is a barrier

Tell us. It is a normal part of the conversation and it changes what we recommend rather than embarrassing anyone.

There is often more than one clinically reasonable answer at different price points — a filling that will serve for several years versus a crown that will serve for much longer, or staging treatment across two benefit years so two annual maximums apply instead of one. Sometimes the right answer is to stabilise a problem now and plan the definitive work for later, which is a legitimate clinical decision, not a compromise.

What is worth avoiding is leaving something untreated because the conversation never happened. Dental problems are almost always cheaper to deal with earlier than later.

Paying

• Payment is due at the appointment for the portion not covered by insurance.
• We accept debit and major credit cards.
• Ask about payment arrangements for larger treatment plans. It is a normal question and worth raising early, because it can affect how treatment is sequenced.
• Where cost is a constraint, say so. There is often more than one clinically reasonable approach at different price points, and treatment can frequently be staged over time.

Common questions