MetLife won't pay my dentist...do I have to pay? (cost, procedure)
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My dental insurance, MetLife, paid my dentist only a fraction of the amount he charged for some deep cleaning. They have their own consultants who review the bill and decide how much they pay. They said this deep cleaning wasn't needed. This year they only paid my dentist about $300 out of the $2,000 annual max. My dentist wants me to pay what the insurance didn't pay. Do I have to pay? Thanks.
My dental insurance, MetLife, paid my dentist only a fraction of the amount he charged for some deep cleaning. They have their own consultants who review the bill and decide how much they pay. They said this deep cleaning wasn't needed. This year they only paid my dentist about $300 out of the $2,000 annual max. My dentist wants me to pay what the insurance didn't pay. Do I have to pay? Thanks.
Yes, you do. You got the work done, you are ultimately responsible for the bill. "Deep cleaning" is rarely medically necessary, and therefore usually not coverable at all.
If you had car insurance and had the interior detailed because the car was old, would you assume your insurance company would pay for it? Would you even *ask* someone if you should pay the car detailing guy to do the work?
Next time, have your dentist communicate with the insurance company and get pre-approval *before* any of the work is done. And then, you'll know what they'll pay and what they won't pay.
If your dentist is a participating provider with Met Life, he is not allowed to charge you the difference between what he charges and what Met Life pays.
However, if he doesn't participate with Met Life, then he can indeed bill you for the difference.
Normally I would suggest having the dentist office submit a pre-determination claim prior to you having any expensive procedure done so you know how much your insurance will pay. But I think that Met Life is one of the few companies who don't do pre-d's. You can always call them and ask though.
What your insurance covers is between you and your insurance company. It should be spelled out in your contract. That contract may also specify how much the insurance company will pay for a specific procedure.
Read the contract!
Does it specifically exclude all "deep cleaning"? Does it specify the circumstances under which "deep cleaning" will be covered? If so, does your personal situation fit those circumstances? If "deep cleaning" is sometimes covered, is there a fee schedule that tells how much the insurance company will pay?
Does it not mention "deep cleaning" at all?
If it does not mention "deep cleaning" at all, then it should be covered. If it does, your premium is based on the limits on the procedure defined in the contract. You paid for a limited level of care.
The amount paid for the procedure depends on the relationship between the dentist and the insurance company. If the dentist has a contract with the insurance company specifying a fee and that you will not have to pay more than that, then the dentist must honor that contract.
If the dentist has no contract with the insurance company, then you owe the balance after the insurance pays what it agreed to in its contract with you.
Know what your insurance covers before you have anything done.
If your dentist is a participating provider with Met Life, he is not allowed to charge you the difference between what he charges and what Met Life pays.
However, if he doesn't participate with Met Life, then he can indeed bill you for the difference.
Normally I would suggest having the dentist office submit a pre-determination claim prior to you having any expensive procedure done so you know how much your insurance will pay. But I think that Met Life is one of the few companies who don't do pre-d's. You can always call them and ask though.
The OP sounds like he's referring to a different type of plan. Metlife has more than one type, and various group plans. It sounds like he's saying Metlife paid the dentist (actually, it doesn't just sound like that - that's exactly what he posted). In the plan you're referring to, Metlife doesn't pay the dentist anything. The preferred provider plan just makes an agreement with the dentist, that the dentist will only charge "x" dollars for "y" procedure, and in exchange, the dentist gets to be on the list of providers and gets a lot of Metlife's customer base.
In the plan the OP is talking about, the dentist gets paid by Metlife a percentage of whatever fee is agreed upon (which *includes* what you're talking about, but is more than just that criteria). And the patient is responsible for the balance.
In the OP's case, Metlife paid their portion of the agreed-upon fee, and the patient is responsible for the balance. Usually it's like an 80/20 program, with Metlife paying 20% and the patient paying 80%. And even then, it is often paid by Metlife only -after- a deductible is met, and even then, Metlife will only pay that 20%, if Metlife hasn't already paid a certain yearly maximum for that patient's dental costs.
If it does not mention "deep cleaning" at all, then it should be covered. If it does, your premium is based on the limits on the procedure defined in the contract. You paid for a limited level of care.
Not always. In many cases, the contract is an inclusionary contract, not an exclusionary contract. In other words - it says "We will cover x, y, and z. We will also cover 2, 7, and 46. We will also cover 9a, b7, and 73.2. Everything that is not specifically mentioned in this contract, is NOT covered."
Mine's like that. It covers specific things. Everything that isn't specified, isn't covered at all.
Not always. In many cases, the contract is an inclusionary contract, not an exclusionary contract. In other words - it says "We will cover x, y, and z. We will also cover 2, 7, and 46. We will also cover 9a, b7, and 73.2. Everything that is not specifically mentioned in this contract, is NOT covered."
Mine's like that. It covers specific things. Everything that isn't specified, isn't covered at all.
As long as the disclaimer out everything else being excluded is included in the language of the contract.
If that is not there I would expect it to be covered.
It still boils down to knowing the language in your personal policy contract.
I am covered under my employer group plan. My plan pays 80%. I pay 20%. I already paid the deductible and the 20%. My dentist chooses what procedure to perform. Therefore he should square that with the insurance company. I don't tell him to do this procedure or that procedure.
I am covered under my employer group plan. My plan pays 80%. I pay 20%. I already paid the deductible and the 20%. My dentist chooses what procedure to perform. Therefore he should square that with the insurance company. I don't tell him to do this procedure or that procedure.
But what is covered depends on the wording of your insurance policy.
I am covered under my employer group plan. My plan pays 80%. I pay 20%. I already paid the deductible and the 20%. My dentist chooses what procedure to perform. Therefore he should square that with the insurance company. I don't tell him to do this procedure or that procedure.
Your plan pays 80% of *COVERED* procedures.
Dental scaling (deep cleaning) is typically *not* a covered procedure. However, your dentist *might* have to charge you less than he charges someone who does *not* have Metlife, because of an agreement with Metlife that the dentist has (not an agreement you have). Which would be why it looked like Metlife paid a tiny fraction and you got stuck with the rest. That wouldn't be what happened - what happened, is that Metlife told the dentist, "we don't cover that procedure, but you can't charge the full amount for it. Charge this instead." And he did, and you're looking at the charge you need to pay, which is less than you -would- pay, if you didn't have any insurance at all.
Like Suzy said - you need to check your contract to find out if what I'm suggesting is what's happening, or if something else is going on. None of us here in InternetLand can possibly know what YOUR contract says. Whatever it says, you agreed to abide by it.
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