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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