Pain-filled mouths, pain-filled wallets.
January 22, 2010 6:58 PM   Subscribe

War: dental office vs dental insurance. War Casualty: patient. What recourse do we have?

We (my wife and myself) have been going to the same dental office for 6 years. They have always been very expensive - when doing comparisons with friends, or quotes online, their fees were always the highest. Between multiple bridges and multiple crowns, we've spent what could have bought us a nice sedan. At the same time, their teams of dentists were always top notch. We have no complaints about the quality of work. We willingly paid the money, because we value the work.

All along, we've had dental insurance.

However, in the last few months there have been multiple occasions where we felt taken advantage of financially - things like being told that the $800 out of pocket I paid for my root canal covered it completely, and I had the option of having doing the filling that day or doing it next week. Next week, a different dentist comes in, and now all of a sudden I owe another $100 for the filling etc. My wife compared notes on the exact same procedures done by a co-worker who has the exact same insurance but a different dental office, and the co-worker pays nothing out of pocket, but we pay $1000 etc. On and on.

So finally, we call the insurance company - yes, sorry it took so long, but we were too trusting. We only called about the last couple of procedures - wisdom tooth extraction, and a crown. The insurance company insisted that for those procedures for which we got codes on the bill from the dental office should have been vastly less out of pocket.

The wisdom tooth consultation should have been $67 out of pocket, we got charged $175. Extraction should have been $150 out of pocket, we paid $240. Crown, we should have paid $890, we paid $1100.

When confronted, the dental office claimed that because there was no pathology in the wisdom tooth they would not get reimbursed by the insurer. The insurer denies this, says "just give us the code, we pay". We even teleconferenced in the insurance rep with the dental office person, where the dental person kept talking about pathology exclusion, and insurance person kept saying "that's irrelevant". Once off the phone, the dental office people claim that there is a special "exclusions and limitations clause" that would have kicked in, had they submitted the claim. We call the insurance company again: they emphatically deny that.

So, we paid the full amount demanded by the dental office. The dental insurance people claim that the dental office is not honoring their contract. As a side note, we went through our bills and codes going back as far as we were with this particular insurance company, and according to their website of claims submitted from the dental office vs what they think we should pay out of pocket shows we were overpaying consistently for virtually every visit for the past two years.

Having totally lost trust in the dental office, we will go somewhere else. However, before I go to war with the dental office, I'd like to know, who is right here - is the dental insurance company BSing us about the coverage, or the dental office is ripping us off? Not knowing how the contract between the dental office and the insurance company works, I can't determine. How does the contract between the dental provider and the insurance company work? Are the dental people luring in patients claiming that they accept insurance X, or Y, then breaking the contract and charging the patient up the wazoo? Or is the relationship between provider and insurance more elastic? I realize we'll probably never get a penny back. But I'd like to go on sites like Yelp and warn people of these shenanigans and rip off... but only if we can be 100% sure of who is guilty here.

So - whew, apologies for the length - can anyone with any dental office / insurance company experience chime in and provide much needed light into this murky situation? I want to be fair, and not besmirch anyone's rep wrongly! Thanks!
posted by VikingSword to Health & Fitness (10 answers total)
I had a question when the bill from my dental officas was exactly twice what my insurance company said. Turns out it was a mistake, but I learned that the agreement between my dentist and the insurance company actually sets the price that my dentist is allowed to charge me, and if they breech that contract, it's between the two of them. I'd ask the insurance company whether this applies in your situation. I'd also check with your state's licensing board to see if there is any precedent in your area for what kind of recourse patients have.
posted by peanut_mcgillicuty at 7:46 PM on January 22, 2010

Write the insurance company with everything you told us and try to get verification of the details back from them in writing. As I understand it (I Am Not A Dental Billing Professional), dental offices contract with insurance companies to provide services at pre-negotiated rates. No matter how much the dental office may want to charge you, they can only bill you the out-of-pocket share as set by your insurance company based on the negotiated price. In other words, they have agreed with your insurance company not to charge you more than X, and they charged Y instead, where Y>X. Not cool.

If you're persistent enough, the insurance company may send a Strongly Worded Letter to your dentist ordering them to knock it off or maybe even exclude them as a provider all together. You might want to see if you can sic your office's benefits person on this as well (assuming you get your dental insurance through work) as insurance companies listen to their customers the best, and their customers are primarily the employers.
posted by zachlipton at 7:52 PM on January 22, 2010

Peanut and Zach are absolutely right; the rates are set and contracted between your dental care provider and your insurance company. If your dental care provider is charging you in excess of the agreed upon rates, they are violating that contract.

We had a similar situation with our former dentist's staff. After going back and forth between the dentist's billing clerk and our insurance company (who agreed we were in the right), I escalated the issue to our insurance company's Board of Trustees Appeals Dept. I wrote a brief letter outlining all of the relevant facts including the dates of the appointments and the amounts I believed were unfairly charged. It took less than three weeks for them to determine that we'd been overcharged; they took care of everything as far as dealing with the dentist's staff and we were sent a reimbursement check that same week.

Look on the back of your bill or call your insurance company and find out where you should send your letter of appeal. Don't let your dentist's staff jerk you around.
posted by LuckySeven~ at 8:27 PM on January 22, 2010

I used to question my dentists's charges, because he was billing both of my insurance companies. (Yeah, I'm very lucky that way) But the secondary insurance was paying the residual, the patient amount, the co-pay, whatever you call it.

Point being that I found out that everything was being done correctly once I looked into it.
You however, have looked into it ad nauseum and are not satisfied that you have been correctly charged.

Why are you continuing to give the dentist office the benefit of the doubt? Based on your story above, there is no doubt. You verified with the insurance rep, you verified with the insurance website, your dentist's staff admitted that they did not bill some things because they thought they wouldn't be paid (a feeble excuse, and not even applicable to most of your treatments).

What clinches it for me is that your dentist's office is saying the insurance company "would have" excluded the payments. If they have submitted the full amount and not been properly reimbursed, then they have something to discuss with you. But they are admitting that they didn't submit. IMHO, they are full of it and you are justified in hanging them out to dry. And even asking for a refund of the over charged amonts.

Definitely file a formal complaint with you insurance company.
posted by SLC Mom at 8:36 PM on January 22, 2010

i agree with above posters that your dental office seems the most unhelpful here. and additionally, what does the dentist himself/herself say? i've had billing questions before too, and while the office is the primary actor in that role, i've always felt comfortable talking directly to the dentist (and getting good info/results by doing so).

the only possibility that would explain why you are being charged more than the insurance's set rates, is if your dentist is out-of-network. The insurance can set the prices that an in-network dentist could charge you (and then pays the in-network dentist a certain rate per particular procedure), but an out-of-network dentist can charge whatever he/she wants, is reimbursed that same price the in-network dentist receives from the insurance and then you are responsible for the difference. But if the dentist never even submits a charge to the insurance???? Sounds like they just don't feel like doing the paperwork -- it is much easier to take your money up front.

My out-of-network dentist also takes money upfront, but I am given a clear estimate on the total cost (just in case the insurance refuses to pay), the dentist's best guess of how much will be covered, and then how much i will probably owe. They submit alllllllll bills to the insurance for me so that I receive my reimbursement within a week.

Since your dentist did not submit certain procedures to the dentist (for reasons that are unsatisfactory to you and the insurance), can you not just submit them now on your own? Your insurance should be able to let you know if it's too late for some claims, and how to go about doing for the relevant claims.
posted by Tandem Affinity at 9:30 PM on January 22, 2010

I covered this with Viking in MeMail, but for anyone else in this position in CA-- the state Department of Insurance considers this insurance fraud by way of inflated billing. That means you can report the practice to the state, and they will lean on the wrongdoers to clean up their act.
posted by fairytale of los angeles at 10:00 PM on January 22, 2010

There is not necessarily a contractual arrangement between the dental office and the dentist. Most dental plans will pay a (low) set amount for the dentists under contract, and if you go out of network then the pay something like 50% - 80% of reasonable and customary rates for the area. Either way, the dental office should be submitting the claim first, then billing you for what the insurance does not pay. (Assuming they are not under a contract). Or they can file a pre-claim and find out exactly what will be covered so they know what to charge to you. This guessing at the reimbursement thing is weird and doesn't sound like a sound business practice at all.

BTW, I totally understand your willingness to pay more for good dental care. The contracted rates paid by the dental insurance firms are so low that I don't want anybody willing to work for that anywhere near my mouth with a sharp metal instrument. So we've always picked our dentist based on comfort with their work and just dealt with the fact that we were paying more than we necessarily had to.
posted by COD at 7:24 AM on January 23, 2010 [1 favorite]

Agree with COD. Lots of dentists do not participate in any networks (and therefore there is no contract, no agreement for the dentist to only bill pre-negotiated rates for services/procedures).

My dentist is not in network for any plan. When I go, he will accept what my dental plan pays for cleaning as paid-in-full. However, for fillings, I end up owing about $65 each time because what my plan pays doesn't cover what my dentist bills.

So, is this the situation? Is your dentist in your network, out of network, or does he/she accept plans at all? It's not like medical doctors where almost everyone is in a network.
posted by FergieBelle at 10:09 AM on January 23, 2010

Thank you everyone for your answers so far - and anyone else, please feel free to chime in!

This dental office is definitely in network. We verified that.

As to submitting the bill - we argued with them, and asked them repeatedly to submit the bill to the insurance company, and if (as is their stated reason) they don't get paid on this claim, then we will gladly pay instead once we see the denial - after all we paid vast sums over the years without complaint, so we are good for the money. They flatly refused - "we won't submit because we are sure the insurance won't pay" (this despite the fact that on the phone the insurance rep TOLD the dental office person that they would!). I figure what is happening is that the dental office picks and chooses which claims they'll submit and which they won't, because for some things, they don't want to submit not because the insurance won't pay, but because then they'd be bound by the upper limit of what can be charged for this procedure - but if they don't submit, then the sky is the limit and they can charge whatever it is they feel like. The insurance company rep claims that they are violating the contract. We are angry because we pay for insurance for a reason - otherwise what's the point? Meanwhile, the dental people are scamming by false advertising "yes, we accept this insurance" to lure you in as a patient, then once they've got you in their clutches, they'll violate the contract and you're screwed. And they have you over the barrel - like when I was assured that the $800 will cover my RC totally and I can have my filling now - it's all paid for (I paid ahead of time) - "but maybe it's better to wait a couple of weeks to see if there are any other problems and then have the filling done at any time" (says the original endodontist)... well, when I come in to have the filling done, a different dentist appears, and now it's an extra $100 for the filling - and no amount of arguing does any good, and what can you do - not have the filling done? They got you over a barrel. Yeah, we've had it.

And this is the problem - as the answers here show - opinions appear divided over how firm such contracts are. So f.ex. our insurance claims we are absolutely due a lower fee of $67 for the consult, but the dental people say "no, it's $175 because there is no pathology" (even though pathology is not relevant according to 2 different insurance reps we spoke to, one of whom told that to the dental person on the phone). Same with the extraction $150 vs $240.

Regardless, we utterly lost trust in these folks. They do good work, but it feels awful to constantly have a feeling like you're being chiseled AND paying insurance. If they told us outright - no, we don't accept insurance, we'd be fine. But this BS where we pay for insurance and they are still ripping us off left and right is not OK. And then it's like pulling teeth(!) trying to get them to explain any charges - curt, hurried and evasive or stonewalling. We're gone.

But I'd like to give feedback on Yelp - so if anyone has firm ideas, speak up! I really want to make sure we're right - I guess I feel great care must be taken before charges are leveled, and it doesn't help that I don't always feel like the insurance people have a firm grasp of the issues either.
posted by VikingSword at 1:26 PM on January 23, 2010

You can't be 100% sure who is guilty until you make copies of all of these bogus charges and submit them to your insurance carrier's Board Of Appeals. They know what your in-network provider is supposed to be charging because they have the contract and you don't. There's no reason to make this more difficult than it has to be. You're focusing too much on Yelp, imho, and not focusing enough on the fact that you've been cheated and are owed money. Let your insurance carrier do their job and help you.

The dentists office's claim that they were charging you in advance because they "knew" your insurance wouldn't pay anyway is total b.s. The dental office is supposed to submit (to your insurance carrier) what's called a "Notice of Pre-determination" before every procedure you've scheduled; it tells the carrier what they intend to charge on a line item basis. When that gets approved, the dental office is supposed to tell you before your appointment if you will be responsible for any out of pocket charges.

This is what happened to us. The dental office neglected to send in any notice of pre-determination and instead, sent us a bill for over $500 dollars after the fact. I wrote to the Board of Appeals (their address was on the back of the bill) detailing the facts and emphasizing that we weren't informed of the out of pocket expenses until after the work had been done. I also let them know the dates and times I'd contacted the dental office to work this out and every excuse they made for overcharging us. They took over from there. A few short weeks later, we were informed we won our appeal.

You need to organize your paper trail and appeal this and all of the other overcharges you've paid. Stop worrying about Yelp for now and at least try to get your money back. I'm outraged on your behalf. Since your former dental office is an in-network provider and under contract with your insurance carrier, what they're doing is in clear violation of their contract. You owe it to yourself and other members of your plan to formally address their abuses so they can be rectified, or, failing that, kicked out of your plan's network and (as fairytale of los angeles recommended) reported to the state for insurance fraud.
posted by LuckySeven~ at 6:33 AM on January 26, 2010

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