Q. I have visited over 3 dentists in the past year and have had the same problem. I went to dentist to get a cap put back on. They focused more on the X-rays and cleaning. I ask for a quote for the cleaning and they said $150 was my portion and the insurance would cover the rest. Instead I got a bill for $600 and they said on the bill that the insurance company did not cover the service. I was specific and said I do not want any work unless it is covered by insurance or I was given an upfront quote I would first have to approve. Why does this keep happening? Are there laws?
I have great dental insurance and I am not sure why every visit requires so much cash and why can�t dentists give exact estimates? Some are even requiring up front payment.
I want my teeth worked on and yet I do not feel comfortable visiting a doctor that ends up screwing me financially. Any steps I can take?
A. I am going to answer your question about dentists not being able to give exact quotes exactly. The reason why we can't is because we have no control over what an insurance company pays, or even if they will pay for a procedure. Most offices, whether they are PPO or not, get what is called a breakdown of benefits. This means that we get general information from the insurance company, regarding the percentages they cover, such as 100% of preventative, 80% of basic, and 50% of major. We also try to get them to tell us of any provisions or limitations with the plan, such as not covering major work for one year or only remaking crowns every 5 years. Insurance companies will tell you over the phone that quotes of benefits are not a guarantee of payment, basically this covers them so that they can not be held responsible if they say "We will cover 50% of any crown you do for this patient." Most insurance companies will not tell a dentist office exactly what they will pay on a procedure.
All insurance companies have what they call "resonable and customary fees." Basically what this means, is that the insurance company chooses a fee for a procedure based on what they feel it is worth. They are not concerned with whether or not this dentist uses the best or the cheapest labs or material, the highest trained staff or any of that. The percentages that they quote are based on these resonable and customary fees. For example: If an insurance company sets a fee for a simple cleaning at $50 and they pay 100% of resonable and customary, they will pay the office $50 for the cleaning. If the dentists actual charge is $70, there are two ways this is dealt with. If he is PPO, or another way of saying it is in-network, he is required to adjust his fee to what the insurance company sets. If he is out of network, he doesn't have to adjust it, and the patient is responsible for the additional $20 not covered by their insurance.
The same goes for any procedure that a dentist does. The uncovered fee is obviously higher depending on the procedure that is done. So for an out of network dentist, the patient would not only pay their copay, they would also have to pay the difference between the reasonable and customary fee and the dentists actual charge. Insurance companies also take into consideration whether or not they feel that the patient really needed a procedure done. They don't care that their dentist says the patient needs it, they have their own "dental claims experts" who decide that. Most of the time these "experts" are either dentists who have lost their license to practive dentistry, dental assistants with at least 7 years experience, or retired dentists. Just because an insurance company tells a dentist that they cover, oh lets say 50% of a crown, their so called experts have to determine if it was really necessary to do the crown, And if they decide not, they don't pay. The same goes for any procedure. There is no way for a dentist office to know without a doubt whether or not an insurance company will cover a procedure, until they submit x-rays, proper documentation, and these "experts" review the claim. They base their copays off of these percentages they get from the insurance company, then they submit a claim, provide x-rays and documentation, and then simply wait for the insurance to pay. If the insurance company says "No, we don't think the patient needed this. We arn't going to pay.", then the dentist is legally allowed to expect the person who recieved the benefits of their services to pay the bill. Meaning you, the patient.
The only way to try to get around this, is to submit a pre-treatment estimate. This tells the insurance company what the dentist plans to do, and then they treat it like they would treat it if it were an actual claim, other than to actually send a check. The insurance companies will still tell you that this pre-treatment estimate is still not a guarantee of payment. So basically what I am telling you, is that there is no way for a dentist to be able to know without a doubt how much or if an insurance company will pay for a procedure. They don't control the insurance companies unfortunatly.
From what you have said, I am assuming that you had a deep cleaning done. Otherwise, a simple cleaning would not have cost over $700.00. Most likely what happened was that the dentist based your copay off of the percentage of what the insurance company said they covered on basic procedures, and then once the insurance company got the claim, they denied it for who konw what reason. That is not the dentists fault, as there was absolutely no way for them to predict what the insurance company would say.
I know this might be hard for you to understand and might seem unfair, but trust me, I have worked in the dental field for 10 years, I am a registered dental assistant, and have dealt with insurance for those 10 yrs. This is unfortunatly the way it is with insurance companies.
Edit: Since I noticed that I got two thumbs downs for my answer, I wanted to just add that my answer was not in any way based on my own personal opinion. It is a factual answer. I don't set the rules that an insurance company makes, however I do understand the rules that they set and was simply trying to explain those rules to you or anyone else who might be confused with insurance plans. If anyone would care to look back at the answers given by the other dental professionals, they will notice that even though they didn't give as much detail about insurance as I did, their answers were basically saying the same thing that I did.
A dental question? I filed a complaint with my local dental society and I had a peer review?
Q. Despite very real concerns, I got a letter from the peer review after examination and I was denied a refund to get my teeth redone.
At the bottom of the letter it states that I may appeal based on "any new evidence or procedural irregularity". Can someone please tell me what a procedural irregularity is? Is that something that was done from my dentist or the peer review committee?
A. Too me it sounds like something the peer review might have missed. I'm totally not sure about that though. You might ask this question in the law section and see what you can come up with.
How do you report a dentist practicing in an altered state of mind (presumably drugs)?
Q. Not sure of the proper name of dental review board in Texas. Please advise. Thanks.
A. I'm not sure of the name either, but look under the county that he/she is practicing in for a dental society and call them. Or you can look under Texas State Board of Dental Examiners.
Hope this helps you.
Are you sure that he/she is on drugs, or is there a possible medical condition? Make sure before you make accusations.
what site can I go to find dentist and their rate in Los Angeles, California?
Q. I'm looking for a good dentist and want to see their ratings.
I don't trust 800 Dentist, because dentists are paying for this site.
A. I'd try Angie's List. It is user-based which means you'll find thousands of users who post unbiased reports and reviews about health care providers (including dentists) in your specific area.
People share their experiences with each other so that you can find the best dentist based on others first-hand knowledge.
You can view the names and numbers of dentists near you. Members will share the type of work they have had done and what they thought of their prices, wait times, etc.
You will have to register, but it's probably worth it. Here is an online coupon to save you $10
http://www.wifinder.ca/angieslist/angieslistcoupon.html
I just checked and there are general dentists, Endodontics/Root Canals, Oral Surgeons, Orthodontics, Periodontics and Denture Specialists.
Powered by Yahoo! Answers
