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I appreciate the information but I never signed anything, I didn't lie to anyone so I don't think I have any culpability in this. I know about Delta Dental, I remember back in the 90's I had Delta Dental and my dentist would waive the co-pay but then he suddenly stopped doing it as result of a lawsuit filed by Delta Dental but that was different than what we are discussing here.
Unfortunately it's not different in the eyes of the insurance company. In fact, it's very simple for their lawyers: Your dentist is reducing your co-pay on a procedure that has a contractually set fee, and you are aware of it. Whether they reduce the copay by 5% or 100%, it's still fraud. Doesn't matter in the least if you signed anything for not. Look at it from the law's perspective - The fact that you are aware of this act that results in financial benefit to you and are going along with it instead of reporting it means (to the insurance company) that you are aiding in this fraud. Don't take it from me - most insurance companies have a fraud hotline. Call them and ask if you can be held accountable for any wrongdoing. Believe me, it might shock you. Delta was just an example. Reducing or waiving co-pays is fraud no matter which insurance company it is. Fraud is fraud.
Again, not trying to start anything or implicate anyone. It is very likely that nothing bad will ever come of this situation. Just trying to give out information from the perspective of the insurance company. Your dentist may simply not understand how insurance works. Or, maybe they do and are trying to game the system. Your dentist may get away with it once or a thousand times, but you don't want to be around if the stuff hits the fan.
Unfortunately it's not different in the eyes of the insurance company. In fact, it's very simple for their lawyers: Your dentist is reducing your co-pay on a procedure that has a contractually set fee, and you are aware of it. Whether they reduce the copay by 5% or 100%, it's still fraud. Doesn't matter in the least if you signed anything for not. Look at it from the law's perspective - The fact that you are aware of this act that results in financial benefit to you and are going along with it instead of reporting it means (to the insurance company) that you are aiding in this fraud. Don't take it from me - most insurance companies have a fraud hotline. Call them and ask if you can be held accountable for any wrongdoing. Believe me, it might shock you. Delta was just an example. Reducing or waiving co-pays is fraud no matter which insurance company it is. Fraud is fraud.
Again, not trying to start anything or implicate anyone. It is very likely that nothing bad will ever come of this situation. Just trying to give out information from the perspective of the insurance company. Your dentist may simply not understand how insurance works. Or, maybe they do and are trying to game the system. Your dentist may get away with it once or a thousand times, but you don't want to be around if the stuff hits the fan.
I appreciate the information and find the subject very interesting But I have some questions
If the dentist charges more for zirconia can the dentist use it if I am willing to pay the difference between zirconia and pfm, or do they have to use PFM? The reason I ask is that it looks like this dentist bills the same for all crown materials, $1161 and accepts what the insurance company will pay.
I also had a crown on #29. I have two insurance policies. The dentist submitted Code D2740 for the crown with a price of $1161. to both companies. One insurance company accepted D2740 and reduced the fee to their network allowable amount of $958. The dentist submitted the same code D2740 @$1161 to the other insurance company and they indicated they would only pay for D2791 with an allowable network amount of $958. So what should the dentist have done? My dentist charged me $958 and used ceramic does that violate the terms of the 2nd company which stated they would only cover D2791? (the two insurance companies do coordinate benefits)
The dentist told me that he used zirconia because the bridge has to be constructed at an angle and zirconia is better suited to that, I don't know if that's true or not- but assuming it is, should he have indicated that to the insurance company?
PS I don't think my dentist looks at insurance pre-approvals, he just sends the treatment plan to his office staff who do the billing and pre-approvals.
I appreciate the information and find the subject very interesting But I have some questions
If the dentist charges more for zirconia can the dentist use it if I am willing to pay the difference between zirconia and pfm, or do they have to use PFM? They can still use zirconia, but generally speaking if your dentist is "in-network" and did a zirconia crown which the insurance company "downgrades" to PFM, then the dentist has to accept the PFM fee and cannot charge the patient the difference. This is the same as my "implants vs RPD" example a few posts above. See what happened - the dentist performed a higher quality treatment but was forced to accept the fee for a lower quality material. Winner = insurance company. The reason I ask is that it looks like this dentist bills the same for all crown materials, $1161 and accepts what the insurance company will pay. For simplicity, the dentist's UCR/private fee for all crowns may be the same, but the insurance fee will differ based on the crown material. The dentist will submit their UCR fee on the claim and will write off the difference between the UCR fee and the insurance fee for the given procedure.
I also had a crown on #29. I have two insurance policies. The dentist submitted Code D2740 for the crown with a price of $1161. to both companies. One insurance company accepted D2740 and reduced the fee to their network allowable amount of $958. The dentist submitted the same code D2740 @$1161 to the other insurance company and they indicated they would only pay for D2791 with an allowable network amount of $958. So what should the dentist have done? My dentist charged me $958 and used ceramic does that violate the terms of the 2nd company which stated they would only cover D2791? (the two insurance companies do coordinate benefits) See my example above. The dentist did an all-ceramic crown (D2740) and the insurance company "downgraded" to an all-metal crown (D2791) - the "less expensive, clinically acceptable" treatment. The dentist had to accept the fee for an all-metal crown when in fact he delivered a more expensive crown. Winner = insurance company.
The dentist told me that he used zirconia because the bridge has to be constructed at an angle and zirconia is better suited to that, I don't know if that's true or not- but assuming it is, should he have indicated that to the insurance company? Honestly, it doesn't matter. If your insurance policy fine print says "no coverage for ceramic materials on posterior teeth" or something like that, then no amount of letters/calls from the dentist with clinical or scientific reasoning on why zirconia is a better choice of material in your case will matter to the insurance company reps. They don't care about the science. All they know is that ceramic is not covered. Period.
PS I don't think my dentist looks at insurance pre-approvals, he just sends the treatment plan to his office staff who do the billing and pre-approvals. This is what most dentists do. Insurance companies are a nightmare to deal with.
They can still use zirconia, but generally speaking if your dentist is "in-network" and did a zirconia crown which the insurance company "downgrades" to PFM, then the dentist has to accept the PFM fee and cannot charge the patient the difference. This is the same as my "implants vs RPD" example a few posts above. See what happened - the dentist performed a higher quality treatment but was forced to accept the fee for a lower quality material. Winner = insurance company. The reason I ask is that it looks like this dentist bills the same for all crown materials, $1161 and accepts what the insurance company will pay. For simplicity, the dentist's UCR/private fee for all crowns may be the same, but the insurance fee will differ based on the crown material. The dentist will submit their UCR fee on the claim and will write off the difference between the UCR fee and the insurance fee for the given procedure....
Ok perfect explanation. I think the confusion comes from my initial statement that the dentist gave me a 'break' which isn't the case. He never said "I'm going to give you a break" I thought I was getting a break because the rip-off corporate dentist I went to wanted $1500 for a zirconia crown which was $300 more than an all ceramic crown and $500 more than a PFM crown. So, when my dentist said he was using zirconia I thought I was getting a discount.
I called the lady who does the billing after reading your post yesterday because I didn't want anyone to get in trouble. She said that the material cost of a crown is negligible and they submit all pre-estimates for crowns as D2740 and the dentist will use whatever material is best suited for the patient and they accept the insurance reimbursement and the patient is never responsible for anything other than their co-pay. She said if a dentist is charging significantly more for zirconia or some other material they are just ripping you off.
I called the lady who does the billing after reading your post yesterday because I didn't want anyone to get in trouble. She said that the material cost of a crown is negligible and they submit all pre-estimates for crowns as D2740 and the dentist will use whatever material is best suited for the patient and they accept the insurance reimbursement and the patient is never responsible for anything other than their co-pay. She said if a dentist is charging significantly more for zirconia or some other material they are just ripping you off.
Does that make sense to you?
All except for the part about the billing lady saying the patient is only ever responsible for their copay and nothing else. The patient is responsible for the ENTIRE cost of the procedure no matter what. If your crown is $900 and your copay was $450, then the dentist will collect that part from you and bill your insurance company for the remaining $450. If your insurance company doesn't pay, or pays less than what was expected, you are responsible for any balance. This is why sometimes patients are shocked to get a dental bill a month or two after getting some work done. Its because the claim was submitted to the insurance company for the other portion and the insurance company didnt pay. The patient thinks "I paid my part, that's all I owe". Nope, read the paperwork you signed your first visit - services are rendered to the patient, not the insurance company. Patients are responsible for all fees regardless of insurance coverage.
If your insurance company fails to pay for your treatment and the dentist purposely intends to write that off without attempting to collect the balance owed from you (in other words, accepting your copay as payment in full), then that is the overbilling I described and is insurance fraud.
All except for the part about the billing lady saying the patient is only ever responsible for their copay and nothing else. The patient is responsible for the ENTIRE cost of the procedure no matter what. If your crown is $900 and your copay was $450, then the dentist will collect that part from you and bill your insurance company for the remaining $450. If your insurance company doesn't pay, or pays less than what was expected, you are responsible for any balance. This is why sometimes patients are shocked to get a dental bill a month or two after getting some work done. Its because the claim was submitted to the insurance company for the other portion and the insurance company didnt pay. The patient thinks "I paid my part, that's all I owe". Nope, read the paperwork you signed your first visit - services are rendered to the patient, not the insurance company. Patients are responsible for all fees regardless of insurance coverage.
If your insurance company fails to pay for your treatment and the dentist purposely intends to write that off without attempting to collect the balance owed from you (in other words, accepting your copay as payment in full), then that is the overbilling I described and is insurance fraud.
I understand what you are saying. I had to pay for a procedure that the insurance company denied payment for, I am not sure how to explain it though so forgive me if this is wrong. I had decay at the base of a crown, the dentist said he had to use a laser to cut the gums away from the base of the crown to access it. They submitted a claim for a gingivectomy and it was denied stating that they only cover gingivectomies for periodontal treatment. The submitted claim was $257. The allowable amount was 0. I paid $257 for the procedure.
I understand what you are saying. I had to pay for a procedure that the insurance company denied payment for, I am not sure how to explain it though so forgive me if this is wrong. I had decay at the base of a crown, the dentist said he had to use a laser to cut the gums away from the base of the crown to access it. They submitted a claim for a gingivectomy and it was denied stating that they only cover gingivectomies for periodontal treatment. The submitted claim was $257. The allowable amount was 0. I paid $257 for the procedure.
Not sure how long ago that was, but the newest set of CDT codes has a code specifically for gingivectomy around a tooth to allow access for a restoration. This would have been the proper code to submit instead of the one for periodontal disease. Again, if this was more than 3 years ago or so then the code did not exist at that time. It still may not have been paid for depending on the specifics of your insurance policy.
Not sure how long ago that was, but the newest set of CDT codes has a code specifically for gingivectomy around a tooth to allow access for a restoration. This would have been the proper code to submit instead of the one for periodontal disease. Again, if this was more than 3 years ago or so then the code did not exist at that time. It still may not have been paid for depending on the specifics of your insurance policy.
It was a month ago! And I bet I know what the correct code is, D4212, right? She submitted D4211 so I asked my old neighbor who is a Pedodontist why he thought it was denied and he said it should be D4212 I told her that and she said ok she would resubmit it and when I asked her about it, she said they denied it with that code too, so I paid for it. But I'm looking at what she submitted online on the insurance company website and she apparently submitted 4211 a second time. Plz let me know if it is D4212 so I can make sure it gets resubmitted.
It was a month ago! And I bet I know what the correct code is, D4212, right? She submitted D4211 so I asked my old neighbor who is a Pedodontist why he thought it was denied and he said it should be D4212 I told her that and she said ok she would resubmit it and when I asked her about it, she said they denied it with that code too, so I paid for it. But I'm looking at what she submitted online on the insurance company website and she apparently submitted 4211 a second time. Plz let me know if it is D4212 so I can make sure it gets resubmitted.
D4212 is the correct code in the scenario you described.
D4212 is the correct code in the scenario you described.
Thanks! I'll be getting some money back
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