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I have never in my life heard someone say that they had good dental coverage and never had to pay a penny out of pocket to make up the difference... NEVER!
At least dental costs are more real versus medical costs that are inflated so much to try to get insurance to pay more.
I have never in my life heard someone say that they had good dental coverage and never had to pay a penny out of pocket to make up the difference... NEVER!
*waves hand* I am a NYC area union member. I have 100% employer funded medical, dental, prescription and vision. As long as I stay in network I have ZERO out of pocket costs for any services. The only thing I have paid for out of pocket was my adult orthodontics. They are not covered. But outside of that, I have some expensive work with several root canals and a permanent bridge. When the braces come off it'll be time for a new bridge. My dentist has check with insurance, they will cover 3 implants at 100%.
*waves hand* I am a NYC area union member. I have 100% employer funded medical, dental, prescription and vision. As long as I stay in network I have ZERO out of pocket costs for any services. The only thing I have paid for out of pocket was my adult orthodontics. They are not covered. But outside of that, I have some expensive work with several root canals and a permanent bridge. When the braces come off it'll be time for a new bridge. My dentist has check with insurance, they will cover 3 implants at 100%.
Sounds like a great plan, but I caution you to read the fine print from your dentist and insurance company. YOU are ALWAYS responsible for any services that the insurance does not pay for, even if the insurance company says they will cover it at 100%.
For example - let's say you are missing 3 upper back teeth. You and your dentist discuss the pros and cons of doing a denture versus implants and you opt for the implants. The dentist's office contacts your insurance company and receives a fax that says "implants - covered at 100%". Yay!! You get the work done and pay zero on the day of surgery. Your dentist sends the claim to the insurance company to get paid for the services they performed on you. 2 months later you get a bill from the dentist for a few thousand dollars. You call, irate, and demand to know what this is all about. The dentist office informs you that they sent the claim for the implant fee, and your insurance company sent a response "downgrading" your implants to that of a removable partial denture, citing it as a "less expensive clinical equivalent" and has thus paid out on that, which is far less than what they would have paid for the implants. The dentist says you owe the difference between what the insurance paid (denture) and what you actually received (implants). You tell the dentist "that's between you and the insurance company". They tell you, "No sir/ma'am, services were rendered to YOU, not your insurance company. Your insurance company is one the one walking around with implants in their mouth - YOU are". You check the financial agreement you signed with the dentist and see that it says "I understand I am responsible for all charges, regardless of insurance coverage" or something to that effect. You look on the statement from your insurance company and the fine print says "Coverage is not a guarantee of benefits and exact benefits will only be determined after a claim is received". This means the insurance company can change their mind AFTER you already get the work done. If they can find a way to pay less for your treatment and leave you on the hook for the rest, they will do that 100% of the time.
I see this happen all the time. Heck, do a search here. Countless threads on this forum are people complaining about "fraudulent dentist bills" because the patient simply does not understand how their own insurance works.
Location: East of Seattle since 1992, 615' Elevation, Zone 8b - originally from SF Bay Area
44,054 posts, read 80,100,596 times
Reputation: 56828
Quote:
Originally Posted by Parnassia
Met Life was not looking in your real time mouth before starting to cut. The oral surgeon was. Yes, they had the imagery and diagnosis from your general dentist, but I think I'd want a referral surgeon to double check what else might be going on with the real patient they'd never met before prior to starting their work. There may have been something on the available imagery that wasn't clear, and those images won't show soft tissue issues that might alter the plan. Charging a mere $60 to be conservative and cautious seems like a bargain to me.
I agree. If anything it's the insurance company that I would be unhappy with.
*waves hand* I am a NYC area union member. I have 100% employer funded medical, dental, prescription and vision. As long as I stay in network I have ZERO out of pocket costs for any services. The only thing I have paid for out of pocket was my adult orthodontics. They are not covered. But outside of that, I have some expensive work with several root canals and a permanent bridge. When the braces come off it'll be time for a new bridge. My dentist has check with insurance, they will cover 3 implants at 100%.
Awesome, but it sounds like you should have taken better care of your teeth.
Sounds like a great plan, but I caution you to read the fine print from your dentist and insurance company. YOU are ALWAYS responsible for any services that the insurance does not pay for, even if the insurance company says they will cover it at 100%.
For example - let's say you are missing 3 upper back teeth. You and your dentist discuss the pros and cons of doing a denture versus implants and you opt for the implants. The dentist's office contacts your insurance company and receives a fax that says "implants - covered at 100%". Yay!! You get the work done and pay zero on the day of surgery. Your dentist sends the claim to the insurance company to get paid for the services they performed on you. 2 months later you get a bill from the dentist for a few thousand dollars. You call, irate, and demand to know what this is all about. The dentist office informs you that they sent the claim for the implant fee, and your insurance company sent a response "downgrading" your implants to that of a removable partial denture, citing it as a "less expensive clinical equivalent" and has thus paid out on that, which is far less than what they would have paid for the implants. The dentist says you owe the difference between what the insurance paid (denture) and what you actually received (implants). You tell the dentist "that's between you and the insurance company". They tell you, "No sir/ma'am, services were rendered to YOU, not your insurance company. Your insurance company is one the one walking around with implants in their mouth - YOU are". You check the financial agreement you signed with the dentist and see that it says "I understand I am responsible for all charges, regardless of insurance coverage" or something to that effect. You look on the statement from your insurance company and the fine print says "Coverage is not a guarantee of benefits and exact benefits will only be determined after a claim is received". This means the insurance company can change their mind AFTER you already get the work done. If they can find a way to pay less for your treatment and leave you on the hook for the rest, they will do that 100% of the time.
I see this happen all the time. Heck, do a search here. Countless threads on this forum are people complaining about "fraudulent dentist bills" because the patient simply does not understand how their own insurance works.
I'm 42 and have had this insurance since I'm 7-8 (my father worked here too). We have never once, ever, paid out of pocket for anything. I am careful to ensure my dentist gets pre determination for all major for services (which isn't required). (All of which is clearly spelled out in the membership booklet.)
Actually, my current dentist's office tells you they'll reach out to the insurance for it before you can ask about the process. We've also been careful to ask the question,"Do you accept the insurance payment as payment in full?" with any provider' medical, dental, vision.
If you want to read all about the great medical, dental, vision and prescription coverage I have you can look up 1199 SEIU National Benefit Fund. It's all as I state- 100% employer funded and no cost to me for services as long as I'm in the network. Actually, I'll save you the leg work. Here's a brief overview of the dental coverage: https://www.1199seiubenefits.org/wp-...l-Benefits.pdf
Quote:
Originally Posted by Sydney123
Awesome, but it sounds like you should have taken better care of your teeth.
I'll fill you in... I had gastric bypass surgery 7 years ago. Sadly, an adverse effect of the body's malabsoprtion of nutrients (due to surgery), even with proper supplementation, is potential dental and bone issues. In my case, my teeth suffered. It's not decay or lack of hygiene. It's a lack of nutrition and nutrients reaching all needed areas. I'll take a broken tooth over loss of brain function.
On the plus side, I've not had to pay tens of thousands for work like other people I know in similar circumstances. Prior to age 35 I had exactly one pin hole cavity that I had filled without anesthestic it was so small.
The adult orthodontics are needed as my wisdom teeth came in quickly and jacked up the teeth the coverage paid to straighten as a mid-teen.
Last edited by charmed hour; 06-17-2019 at 03:24 PM..
I'm 42 and have had this insurance since I'm 7-8 (my father worked here too). We have never once, ever, paid out of pocket for anything. I am careful to ensure my dentist gets pre determination for all major for services (which isn't required). (All of which is clearly spelled out in the membership booklet.)
Actually, my current dentist's office tells you they'll reach out to the insurance for it before you can ask about the process. We've also been careful to ask the question,"Do you accept the insurance payment as payment in full?" with any provider' medical, dental, vision.
If you want to read all about the great medical, dental, vision and prescription coverage I have you can look up 1199 SEIU National Benefit Fund. It's all as I state- 100% employer funded and no cost to me for services as long as I'm in the network. Actually, I'll save you the leg work. Here's a brief overview of the dental coverage: https://www.1199seiubenefits.org/wp-...l-Benefits.pdf
**sigh**
You missed the point completely. It doesn't matter how great or crappy your plan is or what your plan "covers" or doesn't "cover". The point is that, for ANY insurance plan, the insurance company always reserves the right to deny your claim if deems so and YOU, the patient, are ALWAYS responsible for all doctor charges NO MATTER WHAT. Just take a look at the fine print on the bottom of the first page of the PDF you posted. Actually, I'll save you the leg work:
[SIZE=1][SIZE=1][/SIZE][/SIZE][SIZE=1][SIZE=1]NOTE: [/SIZE][/SIZE][SIZE=1][SIZE=1]This is not a complete benefit comparison or a contract and should only be viewed as a brief summary to assist you in understanding this[/SIZE][/SIZE]
[SIZE=1][SIZE=1]EmblemHealth benefit program. A detailed benefits description, including limitations and exclusions, is contained within the Certificate of Insurance.
The terms, conditions, limits, and exclusions shown in the Certificate of Insurance shall govern.
[/SIZE]
[/SIZE]
This means the insurance company can change their mind from what they listed above, and what they tell you or the dentist over the phone/fax about your "coverage" is not binding.
As far as pre-determinations go, they are not even worth the paper they are printed on because at the bottom they also say something like "this is not a guarantee of coverage. Exact benefits will only be determined after a claim is submitted". Translation: "We might pay for this, but you have to get the work done first before we decide for sure. Of course, by that point, you will owe the doctor the entire amount if we decide not to pay since you already got the work done."
You missed the point completely. It doesn't matter how great or crappy your plan is or what your plan "covers" or doesn't "cover". The point is that, for ANY insurance plan, the insurance company always reserves the right to deny your claim if deems so and YOU, the patient, are ALWAYS responsible for all doctor charges NO MATTER WHAT. Just take a look at the fine print on the bottom of the first page of the PDF you posted. Actually, I'll save you the leg work:
[SIZE=1][SIZE=1][/SIZE][/SIZE][SIZE=1][SIZE=1]NOTE: [/SIZE][/SIZE][SIZE=1][SIZE=1]This is not a complete benefit comparison or a contract and should only be viewed as a brief summary to assist you in understanding this[/SIZE][/SIZE]
[SIZE=1][SIZE=1]EmblemHealth benefit program. A detailed benefits description, including limitations and exclusions, is contained within the Certificate of Insurance.
The terms, conditions, limits, and exclusions shown in the Certificate of Insurance shall govern.
[/SIZE]
[/SIZE]
This means the insurance company can change their mind from what they listed above, and what they tell you or the dentist over the phone/fax about your "coverage" is not binding.
As far as pre-determinations go, they are not even worth the paper they are printed on because at the bottom they also say something like "this is not a guarantee of coverage. Exact benefits will only be determined after a claim is submitted". Translation: "We might pay for this, but you have to get the work done first before we decide for sure. Of course, by that point, you will owe the doctor the entire amount if we decide not to pay since you already got the work done."
[SIZE=3]
[SIZE=3]
[/SIZE]
[/SIZE]
I think it was you who missed the point I was making. I've this same dental insurance going on 35 years and it's never been an issue. I have never once had to pay out of pocket for anything I have had done. Both while covered under it with my dad and independently as an adult. A claim has never once been denied.
I know exactly what point you're trying to make, I get it. But again, it's never been an issue for me. Should it arise, I will pay. End of story. I don't take for granted the everything will always be "free". I'm always prepared to pay if necessary.
Some people inherit poor teeth and no matter how good of care they take they will have issues and need lots of dental work. Also any conditions that cause dry mouth take a toll on your teeth. These can be medications or a CPAP machine. I hate it when ignorant people say just take care of your teeth. It would be nice if it was that easy for everyone.
You don't want the person doing your surgery to examine you prior to surgery? Do you really think there is a surgeon who will operate on someone without examining them first so they can make sure they can complete the procedure successfully, and discuss the procedure, the potential complications, and what to expect after surgery?
You should be upset at your crappy insurance for looking for a way to not pay for necessary services. This is how dental "insurance" works. It's not really insurance. It's just a gift card for certain treatments for a limited number of times. Why aren't you upset with the general dentist who charged you for an exam when he was not able to provide a solution and had to refer you out? Did he waste your one time exam??
This is absolutely true. You shouldn't blame the dentist. If you have to blame anyone, blame your insurance company, or even yourself for not understanding how it works.
Of course the dentist who did the surgery would need to examine your mouth for him/herself. You can read what other dentists thought of the situation, but ultimately the dental surgeon was responsible for what happened to you and for their actions.
Here's an analogy - when my mother was alive and riding in the car with me (I was driving and this happened multiple times) she would say, "Oh, it's clear, go ahead" and then get mad at me because I wouldn't go until I looked for myself to make sure the road was clear. I was the one responsible for what happened and no way was I going to go by what she told me!
When you are responsible for something, you should always investigate the situation for yourself and not depend on others, so don't blame the dentist!
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