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Old 09-25-2007, 06:53 PM   #1
weiv0004
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Default Dental Insurance Question

I recently had some dental work done, it was going to be pretty expensive (drilling & filling 5 cavities) so I had the dentist send an estimate in to my insurance company to see what it would cost me.

The form we got back from the insurance company listed the following:

Submitted Charge - 1180.12
Considered Charge - 560.12
Covered Charge - 374.12
Deductible - 25.00
Payment rate - 34.60
Benefit - 314.52

I had no idea what this meant, so I asked the person who handled insurance claims at the dentist, as well as a person from the insurance company, both who told me i would be responsible for "the difference between the covered charge and the considered charge."

Today I got a bill from the dentist for 890.02. Did I talk to two morons, and now I'm out ~$700, or does anyone have a better explanation here?
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Old 09-25-2007, 06:57 PM   #2
Gunslinger08
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Default Dental Insurance Question

You'll actually pay the difference between the benefit and the submitted charge. I don't know what "payment rate" is, but the rest of it is perfectly normal. Dental insurance companies have a certain rate that they deem appropriate for every procedure (your "Considered Charge" of $560.12). Looks like they pay about 66-67% of that (your "Covered Charge" of $374.12) and then subtract from their portion your yearly deductible ($25.00) and whatever the payment rate is.
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Old 09-25-2007, 07:07 PM   #3
msparish
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Default Dental Insurance Question

If your dentist is member of your insurance plan, then they can only charge what the insurance says is allowed. In this case, it looks like it is the "considered charge." Call your dentist, and they should take care of it.
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Old 09-25-2007, 07:10 PM   #4
Jugernot
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Default Dental Insurance Question

1.Submitted charge = Total of all work
2.Considered Charge = The total of the work that was done that they will cover
3.Covered charge = what they won't cover from 2.
4.Deductible = Your deductible, you pay this no matter what.
5. Payment Rate = Not sure what this is
6. Benefit = the total they will pay.

2 - 1 = $620

3 - 2 = $186

4 + 5 = $59.60

Add altogether for your total. At least, that's what it looks like to me.
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Old 09-25-2007, 07:13 PM   #5
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Default Dental Insurance Question

Damn fool, you got owned
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Old 09-25-2007, 07:17 PM   #6
techs
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Default Dental Insurance Question

Quote:
Originally posted by: weiv0004
I recently had some dental work done, it was going to be pretty expensive (drilling & filling 5 cavities) so I had the dentist send an estimate in to my insurance company to see what it would cost me.

The form we got back from the insurance company listed the following:

Submitted Charge - 1180.12
Considered Charge - 560.12
Covered Charge - 374.12
Deductible - 25.00
Payment rate - 34.60
Benefit - 314.52

I had no idea what this meant, so I asked the person who handled insurance claims at the dentist, as well as a person from the insurance company, both who told me i would be responsible for "the difference between the covered charge and the considered charge."

Today I got a bill from the dentist for 890.02. Did I talk to two morons, and now I'm out ~$700, or does anyone have a better explanation here?
First off you never believe anything the dentist or the insurance company tells you.
Basically, unless your dentist is covered under a PPO (preferred provider organization) contract to only charge you what the insurance compay says is the U and C (usual and customary), you must pay whatever amount the dentist says is his charge, unless you make prior arrangements to pay less (legally then, he could not bill the insurance company any more than this amount).
In your case the dentists charge was clearly 1180.12. Since you had no arrangement to pay less, that is what the dentist is entitled to in payment for your procedure.
Your insurance contract almost always allows the insurance company to only allow what they consider to be the U and C for your procedure in your area. There is book published every year that actually lists this, usually by zip code and procedure. So that is what is normally called the insurance rate. In your case I am assuming this is the Considered Charge of 560.12.
However, for many procedures some aspects may not be covered under the insurance plane, for example a part of the procedure that is considered cosmetic. Also, some dentists break down their charges into each separate part of a whole procedure, but the insurance company often disregards these parts since they are usually covered as a part of the greater procedure.
I am guessing that might be the Covered Charge. The covered charge could also be a fundamental limitation of your plan, such as a yearly maximum.
It is also possible that the percentage of payment under your plan is being assessed under covered and considered charges (for example a bridge might be covered at 50 percent, bu the tissue preparation may be at 80 percent)
The deductible is self explanatory.
The payment rate, I am not sure about.
As far as listening to the insurance company person, you cannot hold them responsible for giving you the wrong info, much like when the IRS gives you the wrong info. Your insurance plan contract is the pre-eminent decider of what you pay.
As to the dentists office person, they are not insurance experts and have never seen your contract. Insurance contracts can have amazing differences between them, some so illogical it takes a lawyer to maybe figure it out.

About 20 years ago I was a dental insurance consultant to some of the largest dental insurance companies in America, so while I don't have the most current info, I do have a pretty good knowledge of how these things work.

Now, since you had 5 cavities, and I don't know what type of fillings were use, nor the number of sides of each cavity, I can only guess that the 1180.12 bill is excessive.
I would go back to the dentist and argue that the 560.12 charge is more in line with what is a reasonable rate for your procedure and try and bargain them down.
In the future you should always find out what the dentist is charging YOU and not the insurance company.
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Old 09-25-2007, 07:20 PM   #7
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Default Dental Insurance Question

Quote:
If your dentist is member of your insurance plan, then they can only charge what the insurance says is allowed.
What kind of plan is that? They can charge whatever they want. They will get paid whatever the plan pays, and you cover the remainder.
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Old 09-25-2007, 07:22 PM   #8
weiv0004
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Default Dental Insurance Question

Hmm . . . thanks for the input folks.

FINALLY got of the phone with the insurance company. According to the woman I talked to, my dentist is a member of their plan and as a part of their agreement, can only charge the "Considered Charge" amount. She said it was probably an "honest mistake" on the dentist's part. I'll give 'em a call tomorrow and see how it goes.

I'll keep my fingers crossed.
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Old 09-25-2007, 07:24 PM   #9
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Default Dental Insurance Question

Quote:
Originally posted by: weiv0004
Hmm . . . thanks for the input folks.

FINALLY got of the phone with the insurance company. According to the woman I talked to, my dentist is a member of their plan and as a part of their agreement, can only charge the "Considered Charge" amount. She said it was probably an "honest mistake" on the dentist's part. I'll give 'em a call tomorrow and see how it goes.

I'll keep my fingers crossed.
Good Luck with the bartering!
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Old 09-25-2007, 08:12 PM   #10
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Default Dental Insurance Question

Quote:
Originally posted by: weiv0004
She said it was probably an "honest mistake" on the dentist's part. I'll give 'em a call tomorrow and see how it goes.
It doesn't sound like a mistake to me. You asked for a quote, they gave it to you, and your insurance told you hold much of it they would cover. You actually did the smart thing and asked before the work was done. Now you are being billed the difference. BTW, that sounds kind of high, I recently paid $50 out of pocket to have a cavity filled (w/ dental insurance which doesn't seem to cover much BTW.)

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Old 09-25-2007, 09:14 PM   #11
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Default Dental Insurance Question

So long dental plan!

I cannot believe it actually made it to the 10th post before this.

Peace

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Old 09-26-2007, 09:20 AM   #12
techs
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Default Dental Insurance Question

Quote:
Originally posted by: Old Hippie
Quote:
If your dentist is member of your insurance plan, then they can only charge what the insurance says is allowed.
What kind of plan is that? They can charge whatever they want. They will get paid whatever the plan pays, and you cover the remainder.

In a PPO (Preferred Provider Organization) many plans do indeed require the dentist to only charge what the plan considers Usual and Customary (as you can see from weiv0004's follow up post he was in one of these type of plans).
The reason a dentist would join this type of plan is that he is put on a list, a Preferred Provider list distributed to those people who have that particular insurance plan, and he gets more patients, so he will accept the lower fees).
And weiv0004, your story happens all to often. Many dentists (and doctors) conveniently forget that they can only charge what the plan says they can charge.
Glad to see you are getting the bill fixed

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Old 09-26-2007, 09:47 AM   #13
Xavier434
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Default Dental Insurance Question

OP, I highly recommend switching your dental plan to CompBenefits. They don't cover percentages of costs like most insurance companies. Instead, they have fixed amounts that you pay for when it comes to each type of procedure. Most of the common fixed amounts (such as fillings) are $0. This way, no matter how much your dentist decides to charge for the procedure, you will always pay the same amount of money for it.

Also, no matter what you do, I highly recommend choosing HMO instead of PPO. HMO will almost certainly cover a lot more of the cost provided you choose to go to a dentist on their list. Most of the time, every good dentist in your town will be on the HMO list because it is much better business for them. The only reason one should ever go with PPO is if they really need to be able to go to whatever doctor they need at any time. Otherwise, the vast majority of PPO plans will charge you like mad. They will not cover nearly as much and they often have more expensive deductibles.

CompBenefits
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Old 09-26-2007, 07:01 PM   #14
weiv0004
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Default Dental Insurance Question

Talked to the dentist today. They did indeed "conveniently forget" to adjust the bill for the dental plan coverage. They told me I owed $245.60, the difference between the "Covered charge" and the "benefit."

Wonder if they would have refunded me if I had just paid the ~$900 they originally asked for.

Thanks for the input folks
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Old 09-26-2007, 07:07 PM   #15
Ns1
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Default Dental Insurance Question

Quote:
Originally posted by: Xavier434
OP, I highly recommend switching your dental plan to CompBenefits. They don't cover percentages of costs like most insurance companies. Instead, they have fixed amounts that you pay for when it comes to each type of procedure. Most of the common fixed amounts (such as fillings) are $0. This way, no matter how much your dentist decides to charge for the procedure, you will always pay the same amount of money for it.

Also, no matter what you do, I highly recommend choosing HMO instead of PPO. HMO will almost certainly cover a lot more of the cost provided you choose to go to a dentist on their list. Most of the time, every good dentist in your town will be on the HMO list because it is much better business for them. The only reason one should ever go with PPO is if they really need to be able to go to whatever doctor they need at any time. Otherwise, the vast majority of PPO plans will charge you like mad. They will not cover nearly as much and they often have more expensive deductibles.

CompBenefits
thanks for the link
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