Medical bill arrives with charges that I wasn't told about before treatment; can I argue against paying?
January 20, 2007 9:48 PM   Subscribe

My dentist has sent me a bill for work done during two visits over the past couple of months; I thought that my insurance was covering everything, and my dentist's office never told me that I would be charged personally. I would like to dispute the charges; do I have a leg to stand on?

The details: I went in for a regular appt in December and had the standard cleaning, xrays, and checkup by the dentist. The appointment had been scheduled by the office manager at the end of my last checkup 6 months prior. I assumed that it was all part of my dental coverage from my dental insurance. I didn't pay anything during the visit, which is normal, because in the past my insurance has covered the checkups.

I went back a week or so ago to get a cavity filled, and I was a little surprised at the end to learn that I had to pay a copay. But I let it roll off my back because the copay isn't very high and it wouldn't be worth arguing. I asked the office manager if I'd have to pay anything else and she said she didn't know, but if anything it'd probably be only a little more because of the way insurance companies usually treat fillings.

Today I come home to find a bill from my dentist for about $200, a combination of charges from both visits that apparently weren't covered by my insurance. (The vast majority is from the latter appointment, when I got the filling.)

I'm upset because I was never told that I would be charged for these services, and had I known, I would've thought differently about choosing which services to receive. For example, I would've turned down the Xrays at my checkup, since they took them last time and I know that you don't need to get them every visit. But the dental assistant had been ready to go with them and 1) never told me they'd cost extra, and 2) didn't even give me a choice to turn them down.

As for the latter appointment, if I'd known that my filling would cost $200 I would have looked into a less expensive solution, or at least a different dentist where I could pay less.

I'm quite upset because I feel like they took advantage of me by not being up front with these charges. I don't deny that I could've prevented this by asking them about it before I let them do anything, but I'd never been charged before and I trusted them to tell me if things would be different. I'd been given no reason to expect that I would be charged.

I'd like to write them a letter explaining my stance and asking them to strike the charges from my record, in addition to telling them that in the future I will require them to give me advance notice of all 'personal' charges that I may be subject to, so that I can make an informed decision about those services.

Do I have a leg to stand on here? Can I really hope that they will wipe the charges? Am I approaching this the right way? I'm new to all of this stuff and I'm not sure what I can really expect. Thank you in advance for your advice.
posted by inatizzy to Health & Fitness (14 answers total)
I can completely sympathize with how you're feeling (my family is drowning in medical debt)... But, in general, the dentist's office will tell you that it is YOUR responsibility to know what your insurance will or will not cover...

I used to work for an optometrist, and we were regularly inundated with all sorts of new insurance plans and new rules from old plans... There was no way we could keep track of everyone's individual insurance (including copays, deductibles, covered services versus non-covered services, etc. etc. etc.)... We would never be so bold as to tell the patient with any certainty what their insurance would cover...

That being said, if you are a long-term patient, your dentist's office might be willing to write off some of your charges if you complain... Be calm and respectful, though... If you're threatening or out of control, they won't listen to your concerns at all.
posted by amyms at 10:04 PM on January 20, 2007

You probably want to take this up with your insurance company. It's possible, for example, that you've maxed out your benefits for the year, which would mean you'd be paying out of pocket for procedures that would normally be covered. I found that out the hard way the year I got my wisdom teeth out.

And yes, it's your responsibility to keep track of your dental coverage, not your dentist's. They can't know in advance what your insurance company will pay (although they can make educated guesses based on their experience, which is what they did) so you should know before you go to your appointments what procedures will be covered and in what amounts.
posted by stefanie at 10:16 PM on January 20, 2007

I'd start by contacting my dentist, informing them that I believed more of this bill should have been paid by insurance, and that I was holding payment until I the case had been reviewed by the insurance company. I'd ask at that time if they could provide records from the insurance company's response to their submission of these expenses. Then I would get in touch with the insurance company and work on figuring out if the bill was correctly submitted, what triggered nonpayment etc.

It's hard to say what is happening based on the information you give. I've had some truly dumb things done with medical charges, submitting the wrong patient ID number (they submitted my social security number instead of the number marked "Patient ID Number" on my ins. card), losing my updated information and submitting a claim to an insurer from an employer I hadn't worked for for 2 years, charging me straight up with the expectation that I would submit the charges to my insurer, but never bothering to tell me this was how they had things set up. So definitely don't give up until your insurance company tells you X amount is not covered. I have never paid the bill in these situations until they were resolved.
posted by nanojath at 10:39 PM on January 20, 2007

The last time I had an unexpected doctor bill that I thought my insurance should have covered, I called the insurance company and just asked what had happened, since I thought the appointment should have been covered. It turned out the doctor's office had just entered the wrong code when submitting it to the insurance company, and the insurance agent was able to fix it over the phone. It's certainly worth contacting them and just finding out what the exact issue is before proceeding.
posted by occhiblu at 10:57 PM on January 20, 2007

You could try disputing it with the dentist, but if push comes to shove, you probably don't have much of a leg to stand on. Assuming the dentist hasn't lost it, somewhere in your file is probably a piece of paper that you signed, basically saying "I take final responsibility for all charges if my insurance company fails to pay them."

That, combined with the fact that it's generally your job to understand what's covered by your insurance, doesn't leave you a whole lot of room. It would seem the only argument you have left is that they didn't give you the opportunity to decline the services, or properly understand the costs involved. I doubt they'll just decide not to charge you; if you have a good relationship with them, they might discount it, but eventually they'll probably just send your account to collection if you don't pay. You can always try to fight, but in my experience it's difficult to argue that you shouldn't have to pay for some service, after the service has been rendered to you -- it puts you at something of a disadvantage.

Under the situation, I think Nanojath's advice is probably the best; I'd talk to your insurance company and see if there might not be some way that the charges could be covered. Then ask the dentist to resubmit the charges -- this is quite common, it happens all the time (ins. cos. will decline stuff for no particular reason sometimes, so it's expected that occasionally you need to call and talk to them, then try again). Maybe there's some way you can get them to pick up the tab. If not, I think you're going to end up having to pay it.
posted by Kadin2048 at 11:08 PM on January 20, 2007

For what it's worth, your dentist usually won't complain if you send him $10 for the next 20 months. It's when you don't pay anything at all that they get pissed off. I had some extensive dental work done a few years ago that couldn't be avoided, and I ended up paying it off over time. It's not like he can undo the filling. I hope this makes it a little easier for you to swallow.
posted by Dave Faris at 11:47 PM on January 20, 2007

It's not clear from your post, since you said that these costs "apparently weren't paid by insurance." Were they denied or has the dentist just not received a payment yet? My dentist routinely bills me for every visit even though my insurance company always pays them within a week or two. At first I panicked, then I learned to basically ignore that first bill from the dentist.

On the other hand, my fiance's insurance company is extremely slow at paying out claims and he actually was told to find a new doctor because of the money they were owed. Of course, this just highlights the fact that in some cases you have to prod the insurance company every step of the way.

Lastly, I agree that we've never encountered a medical office that won't do a payment plan.
posted by cabingirl at 12:36 AM on January 21, 2007

On top of that, you need to find your insurance company booklets/paperwork that they sent you or that your work gave you. What will and won't be covered and *WHY* is in this book (i.e. "X-rays once per calendar year") and that book is the bible as far as your insurance company is concerned -- there's no use pleading your case it if they told you ahead of time it wasn't covered. You should also review that book before you go for a procedure so that you're up to date on the details.

FYI, I keep all correspondence and booklets and bills, etc. from my insurance company in a 3-ring binder on my bookshelf, just so things like this don't "happen".
posted by SpecialK at 6:35 AM on January 21, 2007

For future reference, one reason this may have happened is the time of year of your appointments. Many plans cover two checkups a calendar year. If you have them just under every six months, you might end up with having had them in Jan 05, summer 06, and Dec 06, and the third one wouldn't be covered. If this is the case, from now on, ask the office to check whether you've had your two for the calendar year, and if so, put it off a month until the year changes.
posted by daisyace at 6:48 AM on January 21, 2007

(Yes, I meant Jan 06.)
posted by daisyace at 6:49 AM on January 21, 2007

Have you not received an EOB (Explanation of Benefits) from your insurer in reference to the dentist charges? Insurers generally issue an EOB for any charges they receive. This would give you an idea of what wasn't covered and why.
Generally, it comes down to "reasonable and customary" charges.
As an aside, I once requested that my insurance representative supply me with a list of local doctors whose charges were either at or below the insurers "reasonable and customary" rates. You'd think I'd just asked if I could sacrifice their first-born. No way would they direct me to a "reasonably-priced" doctor.
posted by Thorzdad at 8:01 AM on January 21, 2007

Many good possible reasons for what happened with your insurance payment and suggestions for dealing with it. I want to add that during my experience submitting dental claims we had certain procedures such as composite fillings on back teeth where the insurance company would pay according to amalgam fees. Then to further complicate things, if the dentist is a preferred provider, the write-off that he is contracted to give you no longer applies to composite fillings, only if amalgam had been used.

So if an amalgam filling costs $150, a composite filling for that same tooth is, let's say $200. If insurance pays 75% percent, your copay on amalgam is $37.50. If PPO status applies, they may pay the dentist out of a filed fee of $100.00, write off the $50.00, and pay the 75% ($75), leaving you with $25.00 to pay.

But if that filling was composite($200), your plan would take the fee for amalgam($150), pay their 75%, leaving you paying $87.50. If PPO status applies, composite fillings aren't recognized, only amalgam, so the write-off isn't taken. So you would have: $200 fee, with $75 payment from insurance, leaving you $125 to pay out of pocket.

Oh, and if your annual deductible hadn't been applied yet, add another $50 to your payment. So you've paid $175 for the $200 fee.

I had to explain this to patients over and over and over and over... not my fault, not the doctor's fault, not really the insurance companies fault, because it is in the plan booklet. But I always had the patient's insurance plan right on the front of their chart and all our staff knew if a plan was a traditional or PPO plan and would never even guess on payment from insurance.

In the end, it is the patient's responsibility to know their coverage. We in the dental office don't know if you've maxed out because of oral surgery, or root canal, or perio surgery, if the treatment was outside of our office. We don't know if the coverage stopped because your spouse lost his job. We don't know if HR screwed up and didn't pay premiums on time. We don't know if COBRA expired. We can call the insurance company to confirm benefits on the 28th of the month, only to do the treatment after the month rolled over and then find that plan ended.

Not a rag on you inatizzy, just saying that we all should keep track of these things.
posted by Jazz Hands at 8:46 AM on January 21, 2007

This happened to me when a procedure was suggested, but no warning was given at the time that my insurance would not cover much of it. I was stuck suddenly with a $400 bill (at a bad time, too).

It's dishonest, because the myriad of potential procedures makes it impossible to know ahead of time what is covered. But it's legal, and once they do their work, unfortunately, you are obligated to pay them their fee.

I never visited this dentist again. After politely paying the balance and then politely refusing two phone call attempts to schedule an appointment, I received a "bulk" email from the dentist's office indicating — in an aggressive way, to my taste — that it is my responsibility to know ahead of time what procedures are covered by my insurance.

Fair enough, but if I use my dental coverage again it won't be through that damned quack.
posted by Blazecock Pileon at 10:51 AM on January 21, 2007

Jazz Hands is completely correct -- I worked the front office of a dental office for two years and had to explain the costs to patients who were "suddenly" stuck with treatment bills larger than they anticipated. However, many patients would call, irate that we'd "billed" them what was supposed to be paid by insurance. I would explain to them that we were still waiting to be paid by the insurance company and the computer billing software we used didn't differentiate.

For those that got screwed by their coverage, I felt for them and was always willing to work out a payment plan. In the end, it's the insurance companies doing what insurance companies are good at doing (that is, limiting their coverage and holding on to money for as long as possible).

In my current life, I always ask about prices upfront and know what my insurance company's limitations are. My insurance won't pay for composite fillings, for instance, but I'd rather have a composite and pay the extra than deal with all the metal in my mouth. I also know that I have a $1000 coverage maximum (by the way, this cap on coverage hasn't changed in 10 years, despite dental costs increasing) and that they only cover 1 cleaning every 6 months (and not 2 cleanings a year -- which means they won't pay for a cleaning that's scheduled 5 months and 15 days of the previous cleaning).
posted by parilous at 12:05 PM on January 21, 2007

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