What Is Balance Billing?
Balance billing is when a patient is responsible for paying the difference between what their insurance plan covers and the total cost of the dental treatment.
Here’s a simple example:
- The cost of a procedure is $300
- Your insurance covers $180
- The remaining $120 is not paid by insurance—that’s what we call the balance
- This amount is billed to you
Here at Midland Avenue Dental we will direct bill to your insurance company and wait for payment, this is assignment of benefits. Balance billing occurs when your plan doesn’t cover the full cost, and you are responsible for the difference.
Why Doesn’t Insurance Cover Everything?
Most dental insurance plans in Canada—whether through an employer or purchased privately—have annual limits, co-payments, and coverage percentages (like 80% for basic care or 50% for major work). Plans also vary in terms of:
- What procedures are covered
- How much they reimburse for each procedure
- Whether they use a specific fee grid (like the Ontario Dental Association Fee Guide)
- If they are running on a current year fee grid, or previous year’s
If your plan reimburses at a lower rate than the current ODA Fee Guide—or doesn’t cover a certain procedure—you’ll be responsible for the difference. That’s balance billing.
How We Help You Avoid Surprises
We always do our best to help you understand your coverage and out-of-pocket costs before treatment. Here’s how:
✅ We follow the Ontario Dental Association Fee Guide
✅ We provide treatment estimates based on the information your insurance gives us
✅ We submit pre-determinations for major treatments when possible
✅ We explain your options and help you plan your care in a way that works for your budget
✅ We encourage patients to contact their insurance companies and ask questions
Please note: Insurance companies do not always disclose full benefit details to dental offices due to privacy laws—so we always recommend that you check directly with your insurer for the most accurate information.
What You Can Do
- Review your plan details or contact your insurance provider to know what’s covered
- Ask us for an estimate before starting any treatment
- Be aware of your yearly maximums, coverage percentages, and deductibles
- Understand your plan’s stance on assignment of benefits (i.e., can we bill them directly?)
Questions? We’re Here to Help.
We know dental billing can be complicated, but our friendly team is always here to help you understand the cost breakdown of your treatment, different treatment options if applicable, send out pre determinations on your behalf, and answer any questions you may have — we’re happy to go over everything with you.
Thanks for trusting us with your smile!