Will the 'missing tooth clause' catch up with me?

October 30, 2006 12:35 PM

The evil 'missing tooth clause": is it reinforced strictly by insurance companies? If they have approved the 'pre-estimate' of a dental implant without demanding proof of the contrary, how likely is it that they will also overlook this when the actual claim is submitted?
posted by of strange foe to Health & Fitness (3 answers total)

I used to manage dental offices (till July) and I feel comfortable saying:

First, there's a lot more to this question than you probably think.
It's likely enough that they'll need a radiograph of the area in question when your claim is filed, unless your pre-estimate has been approved with or without a radiograph*. Please note that a pre-estimate approval is not a guarantee of payment, and the patient is always responsible for the full cost of any procedure not covered by the insurance plan, and the contract prevails, even over such estimates (which is one of the silly reasons they're called estimates). Also, be very aware that if the insurance company overlooks this, pays it and then comes after you for the money, it will not be pretty. F is for fraud in these cases, and your knowledge here on this forum tells me that you know you are outside the bounds of your contract with the insurance company. When insurance companies investigate dental offices for fraud, the government is likely to get involved.

If the tooth was missing when you got coverage, and you want to be an honest person, and not screw your dentist, suck it up and pay for the implant, it's a wonderful technology. On the other hand, if your dental office submitted this pre treatment estimate, knowing that you have a missing tooth clause, someone is in line for fraud investigation, and do you trust an office that steals money?

*A note: not likely but totally possible. Your dentist or dental assistant may have charted your area in question as containting the teeth to be "replaced" by implant retainted restorations, either accidentally or on purpose, and sent that incorrect charting to the insurance company, with or in lieu of radiographs.

In obtaining dental insurance, you may have signed over the right for your current insurance provider to obtain records from any dentist you ever saw.

So, while this doesn't directly answer your question, I hope it makes you wonder whether it is worth the chance of them figuring it out after they pay. If they figure it out and don't pay, they'll just deny the claim, probably without bothering to accuse you of the F word.

Oh, wait, there's more for you to think about... are any teeth being removed to make room for this restoration? Either way, talk to your dentist about exactly how this has been treatment planned, and mention your discomfort (or excitement, or ambivalence) about this paperwork you find yourself with. See what the doc says. Maybe have a meeting with the Business Manager, or the Financial Coordinator, if the doc isn't the person who discusses money with the patients.
posted by bilabial at 1:06 PM on October 30, 2006

On the other hand, if your dental office submitted this pre treatment estimate, knowing that you have a missing tooth clause, someone is in line for fraud investigation, and do you trust an office that steals money?

That's the most important thing anyone will ever tell you - an organization willing to collaborate with you to cheat someone else will be willing to collaborate with someone else to cheat you. Maybe it'll be on quality of care or proper sterilization techniques rather than money, but a dishonest operation is a dishonest operation.
posted by phearlez at 1:30 PM on October 30, 2006 [1 favorite]

Response by poster: The F word certainly puts things into perspectives for me, thanks! (I'd suspected that the 'Let the sleeping dog lie' line of reasoning wouldn't pass muster in this case.)
posted by of strange foe at 4:36 PM on October 30, 2006