Tooth and clause
May 18, 2012 5:26 PM Subscribe
Dental Insurance: I have it for the first time in 20 years. Help me figure out how (if) I can get coverage for a procedure that was pre-approved and then denied coverage.
This is something like my question but not exactly.
After a few years without insurance (and without care) I had four teeth pulled and an implant installed on the same day. The implant was installed because two of the teeth being pulled were anchoring my existing lower bridge. The plan is to attach the bridge to the implant.
However, they didn't put the implant where one of the pulled teeth was (how could they?), they put it right next to it, where I had lost a tooth years before. A couple of weeks later I got a bill for twice as much as I was quoted, because insurance denied the claim.
I have tried to have a discussion about this with the accounts receivable person at the oral surgeon's office where this was done, but she is extremely adversarial and unpleasant, unwilling to listen to or answer my questions.
I did not choose this dental surgeon; my dentist of 20 years sent me to him. My dentist's office manager has always been willing to explain things, and she has always gone to bat for me with the insurance company to get things covered. (Yes, I am spoiled)
I don't know how to explain this to the insurance company, in a way that they will understand and accept. Don't I need the oral surgeon to attest that the implant is to anchor an existing bridge?
I also do not understand why no one mentioned this "missing tooth clause" to me when they were giving me an estimate of how much the implant would cost. I could have waited for the area to heal and had the implant put in a place that would be covered, if i had known. Doesn't the oral surgeon have some responsibility to let me know this could end up not being covered?
This is something like my question but not exactly.
After a few years without insurance (and without care) I had four teeth pulled and an implant installed on the same day. The implant was installed because two of the teeth being pulled were anchoring my existing lower bridge. The plan is to attach the bridge to the implant.
However, they didn't put the implant where one of the pulled teeth was (how could they?), they put it right next to it, where I had lost a tooth years before. A couple of weeks later I got a bill for twice as much as I was quoted, because insurance denied the claim.
I have tried to have a discussion about this with the accounts receivable person at the oral surgeon's office where this was done, but she is extremely adversarial and unpleasant, unwilling to listen to or answer my questions.
I did not choose this dental surgeon; my dentist of 20 years sent me to him. My dentist's office manager has always been willing to explain things, and she has always gone to bat for me with the insurance company to get things covered. (Yes, I am spoiled)
I don't know how to explain this to the insurance company, in a way that they will understand and accept. Don't I need the oral surgeon to attest that the implant is to anchor an existing bridge?
I also do not understand why no one mentioned this "missing tooth clause" to me when they were giving me an estimate of how much the implant would cost. I could have waited for the area to heal and had the implant put in a place that would be covered, if i had known. Doesn't the oral surgeon have some responsibility to let me know this could end up not being covered?
Is there anyone else you can contact at the surgeon's office, besides accounts? If they screwed up the procedure, this could be a problem for them, and you should make it clear to them.
I would also call the insurance to see what's up - what part of the claim did they deny and why? I know with my insurance, I have something like a $1,000 max per year - knowing my rate and dentists, four extractions would meet that - anything else would be above this for the year and I'd have to pay out of pocket (I only know this because this week my dentist wanted me to get two extractions and two crowns, and told me the second crown wouldn't be covered by insurance, because I'd met the limit for the year, so I'm deferring that to the following year).
However, I don't think the oral surgeon has a legal responsibility to tell you it won't be covered....well, let me rephrase that, most doctors already tell you that when you first meet in their office - you sign a paper saying the insurance is your responsibility.
I totally feel for you though - I rely on my doctor the same way....but I'm planning to undergo a procedure that's borderline medical/elective, so I'm going to make sure I call the insurance, not just rely on the Dr.
posted by Lt. Bunny Wigglesworth at 6:07 PM on May 18, 2012
I would also call the insurance to see what's up - what part of the claim did they deny and why? I know with my insurance, I have something like a $1,000 max per year - knowing my rate and dentists, four extractions would meet that - anything else would be above this for the year and I'd have to pay out of pocket (I only know this because this week my dentist wanted me to get two extractions and two crowns, and told me the second crown wouldn't be covered by insurance, because I'd met the limit for the year, so I'm deferring that to the following year).
However, I don't think the oral surgeon has a legal responsibility to tell you it won't be covered....well, let me rephrase that, most doctors already tell you that when you first meet in their office - you sign a paper saying the insurance is your responsibility.
I totally feel for you though - I rely on my doctor the same way....but I'm planning to undergo a procedure that's borderline medical/elective, so I'm going to make sure I call the insurance, not just rely on the Dr.
posted by Lt. Bunny Wigglesworth at 6:07 PM on May 18, 2012
Response by poster: I tried to ask the person who answered the phone, but she transferred me to accounts receivable. I think I may call back and ask to speak to that person's supervisor. I need to get this resolved because in less than a month I have an appointment to get the implant topped.
posted by caryatid at 8:06 PM on May 18, 2012
posted by caryatid at 8:06 PM on May 18, 2012
Your procedure was preapproved with specific tooth numbers indicated, the dental implant code was approved for, say Tooth #28 which was to be extracted the same day as placement of implant fixture, but when surgeon did his work, implant fixture was placed in old extraction site, Tooth #29? Your insurance would have paid the placement of implant if it had been billed as #28? Denied because it was a preexisting missing tooth?
I would go over entire treatment plan, see if what's going to be billed is over your annual maximum anyway. It may be that the money that would have run out sooner because of the payment on implant placement may be ending up being used on treatment later on. You may not be paying more because of this.
Make sure that even if something is billed to insurance and denied for any legitimate reason, you pay only contract fees. Dentists aren't allowed to charge more just because your insurance didn't pay. Ask about cash discounts on fees Insurance doesn't cover contractually.
What is concerning me, is that you say your dentist is going to reuse the bridge? Using the implant to attach bridge to a natural tooth. It just isn't done that way, as far as using implant and natural teeth in same bridge work. It may be that this is a stop-gap measure to keep you from having to replace several units of crown and bridgework at one time. But it isn't usually a longterm solution.
posted by Jazz Hands at 6:56 AM on May 19, 2012
I would go over entire treatment plan, see if what's going to be billed is over your annual maximum anyway. It may be that the money that would have run out sooner because of the payment on implant placement may be ending up being used on treatment later on. You may not be paying more because of this.
Make sure that even if something is billed to insurance and denied for any legitimate reason, you pay only contract fees. Dentists aren't allowed to charge more just because your insurance didn't pay. Ask about cash discounts on fees Insurance doesn't cover contractually.
What is concerning me, is that you say your dentist is going to reuse the bridge? Using the implant to attach bridge to a natural tooth. It just isn't done that way, as far as using implant and natural teeth in same bridge work. It may be that this is a stop-gap measure to keep you from having to replace several units of crown and bridgework at one time. But it isn't usually a longterm solution.
posted by Jazz Hands at 6:56 AM on May 19, 2012
Response by poster: No, the dentist is going to attach the existing bridge (after it is modified) to the new implant. I don't understand what you mean about using natural teeth in bridgework - the bridgework replaces missing teeth, and was in the past anchored (by metal hooks) to natural teeth. The natural teeth that it was hooked to were pulled. Now the bridge will be attached to the implant.
posted by caryatid at 4:09 PM on May 19, 2012
posted by caryatid at 4:09 PM on May 19, 2012
Response by poster: Update (if anyone cares): the oral surgeon has sent me a copy of the letter he sent to the insurance company explaining why the implant should be covered. Apparently there were no exclusions cited so this should be covered. All I had to do, apparently, was hang up on the unhelpful accounts receivable person.
posted by caryatid at 9:23 PM on June 1, 2012 [1 favorite]
posted by caryatid at 9:23 PM on June 1, 2012 [1 favorite]
This thread is closed to new comments.
If the phone call doesn't fix it, then you can start considering appeals through the insurance company, trying to get your oral surgeon to resubmit it under a different code, etc.
posted by deadweightloss at 5:54 PM on May 18, 2012 [2 favorites]