Maxed out Dental benefits - What can I do?

[kittin]

@elizabethc This. 240 is not much over max. Would not be something to cause a 4th over. I am thinking less work was needed

 

[brentlake]

@veronica3 If the dentist is in network, they have to submit a claim to your insurance company per their contract. They have to honor what the insurance company says you owe the dentist on the EOB. So if the EOB says you only owe up to the contracted amount, you can't be charged up to the total submitted amount. The same dental procedure can't be split over different dates of service or benefit years. That would be fraud.

 

[broggyb]

@veronica3 Sorry you're going through this, OP. Dental "insurance" (quotations because most dental plans largely serve as access to negotiated rates rather than actual insurance) has notoriously low annual maximum benefits. In most cases, anywhere between $1,500 and $2,000 per calendar year.

It takes a single crown or root canal to get close to or even exceed the maximum benefit, which means all care moving forward will be out of pocket until the next calendar year. I've maxed my benefits out as early as January for a crown, having to then ride the year out until the following out to resume any meaningful work.

Back to your case - I'm not sure there's "overcharging" going on, rather, balance billing. We can argue all day about the inflated costs of dentistry and the abysmally low coverage thresholds of most dental plans, but we will table that for now. In your case, it seems the dentist's office is billing your dental insurance $X, dental insurance is reimbursing $Y, and the dentist's office is then looking at you to pay the remainder, $Z--likely because for 2023, those three visits / procedures exceeded your plan's maximum annual benefit.

If this is an incorrect assessment, I urge you to upload some redacted images if the bill you're receiving from your dentist along with a redacted copy of the EOB from your insurer to better help illustrate what's going on.

Edit: if your health / dental carrier has a web portal, log in to check any claim history you may have. You can easily tell who has submitted claims to your insurer, when, and for what procedures / services. Highly recommend looking there to confirm the whole "we didn't bill insurance because it wouldn't matter anyway" part of the story.

Edit 2: regarding the dental practice that seems to up to some shenanigans--my expertise falls off a cliff here, but I'd wager there's a relatively simple way to file a complaint with your state's dental board. Definitely keep the pressure up with the office manager--show that they did not adhere to the treatment plan you agreed upon, and that because of that, you're incurring unnecessary costs that otherwise wouldn't have occurred.

 

[veronica3]

@broggyb Hey there,

You nailed my situation. This is exactly what happened. Insurance has been involved, I have requested that the unbilled procedures be billed so I can see in the EOB that the procedures were going to be my responsibility because of the maxed out benefits. But also because if there is a contracted price, I would save some money there.

What I find totally unjustifiable is the fact that she DID contact the insurance AHEAD of the services being performed and she made me PAY for my portion AHEAD of the services being performed for the first TWO visits. On the third visit, when I asked about the bill, she said that she would tell me afterwards. Which I found it strange. When we did talk, she said that it looked like there was a credit and therefore she would charge me less and wait and see what the last EOB would be.

In the end my EOB responsibility to pay was $200 less that what I had already paid. AND, on top of that she now wants another $140.00 for the balance in her ledger.

 

[broggyb]

@veronica3 Got it. I think there's some general accounting errors going on. You're on the right track, which is a pain in the rear to begin with to have to be doing this. It's pretty normal for providers to ask for a pre-pay--happens for all kinds of things, from simple dental work to big ol' surgeries. Basically, they're getting ahead of the drawn out process that is revenue cycle management. In some cases, provider revenue / reimbursement cycles can be between 30-40 days because of the complex nature of the payments and reimbursements systems in place.

It could be a matter of waiting for the dust to settle once the claims have been submitted and simply reviewing the numbers again.

 

[veronica3]

@broggyb unfortunately the insurance paid the provider within days of the bill's submission. Benefits were maxed out already on the 3rd EOB. Not expecting a miracle to happen on the 4th one. It is what it is. TY.