Maxed out Dental benefits - What can I do?

[veronica3]

So, here is the story: This is the second dental practice that maxes out my dental benefits and makes me pay for the full charge. I changed practice because the first one overcharged the insurance for reimbursable benefits by about $400. I was so upset that for 2 years I avoid going to see any doctors.

This last year I went to see a dentist and specifically told the office manager that I would not want to go through the same experience and she understood and told me that the services would be split in several visits with last one being in the new year. Sure enough they wrapped all the work in 3 visits and all charges were made in prior year, resulting in about 240.00 overcharge that they want me to pay out of pocket.

I feel cheated and powerless. What can I possibly do or say to this dentist to reach a reasonable solutions? The office manager is in complete denial and since she made me overpay, she has no intention of reimbursing me of the money that I would have otherwise not paid, because the insurance would have.

Thank you

F

 

[logicweb040]

@veronica3 In my experience, dental insurance is not really "insurance" in the classic sense. It is more of prepayment for certain services with a relatively slight discount on others.

Unless you are only doing your annual check in/cleaning, you are always going to have out of pocket expenses with dental insurance.

The timing of the services is unclear. Are you saying the visits all took place in 2023 and your expectation was that they would bill one of them with a date of service in 2024?

 

[veronica3]

@logicweb040 It was NOT my expectations, it was the office manager telling me that they were going to do so, to avoid maxing out my annual benefits.

Rest assured that dental insurance is identical to health insurance. Only the dentist charges you in advance to avoid that patients refuse to pay the difference, in case there is one. She made me overpay by $200. and then she did not bill the insurance for 4 procedures claiming that the insuranc e would have not paid it anyway. (!!) Now I know why she said that: she did not bill because she did not want me to find out that the benefits were maxed out. Too bad that I am an accountant and put together a spreadsheet to find out what she did.

 

[elizabethc]

@veronica3

Rest assured that dental insurance is identical to health insurance

No it isn't. Most dental insurance is more like a coupon booklet than actual insurance

 

[winston_32]

@elizabethc Best description I’ve ever heard. I have dental issues, and I refer to my dental insurance as pay X, get free cleanings and Y amount worth of work for free.

 

[veronica3]

@elizabethc Sorry, but this is not my case.

 

[foreverthankful]

@veronica3 If dental insurance were like medical insurance, you would have no annual max on benefits. Anything medically necessary that wasn't an exclusion would be covered- if it was $100 or $2,000,000

Dental is a discount program.

What should have happened is you should have monitored all the work and not scheduled your last session until the new year. If the dental office said they were going to wait on the last procedures and did not, that's terrible of them. But it's your responsibility too to help coordinate benefits between 2 plan years if you're trying not to pay out of pocket.

 

[elizabethc]

@veronica3 Then you have better dental insurance than most people. My mom just had to have a minor dental surgery and it cost her $900 out of pocket (insurance didn't cover any of it because she reached her max). And she is lucky it only cost her that much.

 

[kittin]

@veronica3

Rest assured that dental insurance is identical to health insurance.

did not bill because she did not want me to find out that the benefits were maxed out.

Those two sentences are in conflict with themselves a max benefit is an example of a huge difference between the two. They also have different in regulation, difference in how network and payment reimbursement works. Difference in how a doctor can get am estimate of what insurance will pay. Difference in a million different things

Dental is a different beast then health insurance

 

[logicweb040]

@veronica3 So, all the visits and procedures took place in 2023?

 

[veronica3]

@logicweb040 correct.

 

[logicweb040]

@veronica3 There is absolutely no way an office manager was going to agree to commit insurance fraud on your behalf.

They would risk it all by doing so.

If you wanted to split the cost between service contract years, it would have been your responsibility to have the services actually done in different service contract years.

 

[veronica3]

@logicweb040 She did not commit any fraud. She just did her job, and only put 4 procedures on their private billing statement. But did not bill the insurance. When I asked her why, she said she already knew that the insurance would not pay for it. Which is not true, because one of the 4, she had previously billed for another tooth and insurance reimbursed. So I asked her to bill for ALL procedures even if she says she knows that will be denied, because if there is an insurance discount it will be applied AND because they will have to state WHY it was denied.

 

[logicweb040]

@veronica3 Wait. The not billing a service to insurance is new information.

You can certainly have them do so if you want. The end result may be the same, but if you request it they should bill insurance.

If they do not, you can call your insurance and have them contact the office on your behalf.

 

[veronica3]

@logicweb040 the fact that the dental office did not bill the insurance was new to me until yesterday, when I created a spreadsheet and tied the dentist office's charges to the explanation of benefits. She (office manager) did not mention that to me, I found out by myself and she confirmed it, when I asked her. I did call the insurance and they suggested I file a grievance form, which will open an investigation, which I intend to do, IF I can't reach an amicable decision with the practice. Because I am not willing to pay for procedures that would have been covered at 80% plus with discounted rate, had the benefits not been maxed out and performed in 2024 instead of 2023.

When people thinks it is my responsability to decide which procedures I want it done to avoid this issue, THIS IS EXACTLY WHAT I ASKED THE OFFICE MGR, since she is the one that reviews procedures being performed AHEAD of the actual visit. She totally would have known that by performing all the remaining services in the 3rd 2023 visit, I would have maxed some of my benefits, but either she forgot or she did not pay attention.

So here is my question to you: Am I liable for someone else's mistakes after I have been very adamant about this issue?

 

[logicweb040]

@veronica3 Yes, you are responsible for billed services that generate a patient balance.

 

[aletia]

@veronica3 If the claim is fully denied, the insurance will not apply any discounts.

 

[kittin]

@veronica3 Sounds like they are trying but your service needed exceed your plan limits

What do you mean over charge is this out of network and the 240 is over your insurance allowed amount or. Or is over your max benfits?

If they were going to do the 3rd visit in the next year for new visit did you wait till the next year to do thr 3rd visit?

 

[veronica3]

@kittin Hello

What I meant by "services needed exceed my plan limits", was that the treatment plan was split in 4 visits (with the last one going to be in new year, so that the benefits would not be maxed out in 2023. However, I don't know if it was the doctor or the office manager, they treated me in 3 visits (instead of 4) and ALL in 2023, causing the annual benefits to be maxed out. I was not consulted, I did not refuse to be treated in new year, it definitely it was not my decision. I was still expecting a fourth visit, but at the end of the 3rd one, I found out that was all done.

Hopefully this answers your questions.

F

 

[elizabethc]

@veronica3

they treated me in 3 visits (instead of 4)

Why did they do this? Did they do the same amount of work in 3 visits instead of 4 or did they realize that they actually only needed to do less work and so it only took 3 visits to do everything required?