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When I moved to triangle area last year, I have chosen a new dentist in Cary, NC and provided all my previous history. He suggested for a deep cleaning with one quadrant at a time. But at the first cleaning session, they did deep cleaning of all quadrants and applied some additional fluoride treatment. They said it is better to treat all the teeth same day to save time.
After that my insurance company has declined the claim saying frequency of cleaning is less than a year. Now the dentist is asking me to pay twice the claim amount as the claim is declined.
Here my mistake is that I trusted the dentist and went ahead with his plan of treatment as I have provided my complete dental history to his office. I expected them to check my benefits. Even they didn't ask me to get pre-approval for my procedure.
So I offered them to pay the amount that insurance would pay in general. But they are insisting for full amount now. I spoke with insurance, they didn't help me here. They recommended that the provided would have called in advance to get my benefit details.
Is there any option for me to report this issue to NC dental board? How can the dentist be so rigid to get the full payment even though I have very good insurance, but my claim is not approved only due to frequency of procedure. And he is ready to loose a family of 4 people as his patients.
I know some doctors who write off the amount in cases like as there is a communication gap on both sides.
Any advise is highly appreciated.
Do you mind sharing the cost of this procedure? ie How much does your dentist expect you to pay?
If he is in-network, you do not have to, to my knowledge and based on what EOB (explanation of benefit statement) says, pay the charges above what the doctor and insurance company agreed upon
You may check with your insurance if that were the case. Also, you may want to check your EOB statement to see any wording as such
1. This service is only covered for a child. [RVRC - B11]
2. Your benefit plan has a limit for how often this procedure is covered. [026]
4. This procedure is not covered under your dental plan. Your plan provides benefits for a specific list of services. These can be found in your Dental Benefits Plan. Look under the "List of Covered Dental Expenses". [018]
I paid for #1, as #2, #3 are declined. They are asking me to pay double the amount of 540+259=799@2=1598.
My previous dentist has sent me "Dental Predetermination of Benefits" before each treatment and discussed the payment options with me. But unfortunately no such courtesy check is done here.
If he is in-network, you do not have to, to my knowledge and based on what EOB (explanation of benefit statement) says, pay the charges above what the doctor and insurance company agreed upon
You may check with your insurance if that were the case. Also, you may want to check your EOB statement to see any wording as such
As per EOB, I should $799, but they are asking for twice that amount.
Again, please check with your insurance since in-network doctors are not supposed to charge you more than the "Estimated Member Responsibility"
My Dentist typically bills me what it would be the balance after insurance payments. I always tell them, I would pay once I get the EOB. I settle the monies with them after I get the EOB - most of the times, their bills would be more than I actually owe after I get the EOB
Maybe the dentist wants you to pay more because the procedure is only covered at 50% by the insurance company, so even if the insurance did pay, you would still have to pay 50%. So if insurance doesn't pay, you have to pay the full 100%. I don't believe mine would cover a deep cleaning as I have never seen that listed under the benefits.
I don't think the dentist is responsible for only doing procedures that your insurance will pay for. They usually say they will submit insurance as a courtesy but that you are ultimately responsible.
My dentist once did bite-wing xrays and a full panoramic at the same visit. Well, my insurance company had a little clause that said it wouldn't pay for both in the same appointment. I ended up having to pay what my insurance company didn't (even though if I had it done on 2 separate visits they would be covered at 100%) I paid and then switched dentist after that because I was angry that the dentist didn't know better. Their response was that they deal with so many insurance companies, they can't keep track of everyone's benefits on each patient's plan. Now I am very careful to know exactly what my insurance company covers and to verify it before I have any work done. Maybe just use this as a learning opportunity and make sure it doesn't happen again...
1. Obtain all copies of every document you signed that they have on file along with obtaining a copy of the release form. This will prevent much headache in pursuing the next steps. If you have a copy of a document stating you asked for everything you agreed to and they come up later on trying to say you agreed to this and that they are the ones holding the bag. This may involve a copy fee.
2. Call your dental insurance again and ask could they provide you documentation that this office is in-network. In-network means they agree to accept a negotiated rate of fees for services. This doesn't mean they get to be paid what they think they deserve to be paid. For example, speaking from the medical world, if I went and had an outpatient surgery they would bill a certain amount, the insurance says nope we are only going to pay $X b/c you agreed to this in the beginning. Anything insurance would not pay for within the accepted price is then my responsibility.
3. Call a good consumer attorney. After a usual free consultation, you will probably pay less in the long run getting some legal help and you in turn, can ask for compensation for your aggravation and loss in productivity due to this issue if you are indeed correct.
4. It was my understanding scale cleaning is not to be done but around every three-five years. It is disturbing that this was recommended so soon after it was already done.
I hope you get the remedy you need. It is grossly disturbing that finding a decent dentist is like finding a good mechanic.
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Does the insurance pay 100%?
