Exclusion for dentists?

adellabedella_usaJune 5, 2004

Some friends and I were talking the other day. Apparently, one friend had gone to the dentist and had had some dental work done. She has insurance with a $10 copay. She had assumed that she would only be resposible for the $10 since the procedure was covered by insurance. She received an additional bill from the dentist saying that she owed an additional $62 above what her insurance company paid for the procedure. Normally, if you visit a doctor the additional amount would be written off. She called the dentist and the insurer and was told that, unlike doctors, dentists do not have to write off the amount over which the insurance company has agreed to pay.

My friend paid the difference, but won't be going back. There were several others in the room who won't be going there or taking the kids either. This dentist is new in town and I would assume this practice isn't going to help retain patients. Has anyone else heard of this type of practice being legal?

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I have heard of this practice and believe that it is legal, generally. Unless the doctor/dentist has agreed to do so, why should they accept less than their full fee, simply because the patient has arranged for someone else to pay it? Although it is very common for doctors to agree to do so, I do not believe that they are legally required to "write off" charges that insurance companies do not pay. I think that the rules are different when it comes to Medicare or Medicaid reimbursements, however.

Your post says that your friend "assumed" that she would be responsible only for a $10 co-pay. That may be part of the problem. Although your post says she has already paid the difference, she should double-check what the policy covers and what it does not cover. She should then see how that relates to the dentist's actual charges to make sure that there haven't been any mistakes.

    Bookmark   June 6, 2004 at 1:14PM
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I guess my problem with it is that when someone agrees to accept the payment from my insurer, I expect them to accept an agreed upon amount unless otherwise noted. I don't have the same insurance as my friend so I don't know what her exact terms are.

I see this as being a problem for this dentist. She is new to town and has higher prices than the other dentists. Why go to her when I can go to someone more experienced at a cheaper price? This is a small town with lots of word of mouth. I don't go to a doctor or anyone here without asking around.

    Bookmark   June 6, 2004 at 11:56PM
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Dentists are different than doctors in that there is a pretty small list of procedures that they actually perform. And dental insurance has a list of prices that the dentist has to agree to charge.

Typically, dentists don't work on a copay basis. They work on contractually-agreed-upon amounts. If the amount they charged was within the amount listed in her dental benefit statement, then she has to pay.

If they are an approved provider, they can only charge that amount. If she does not have her original insurance papers from when she signed up, she should call her insurance company and get the list of rates for procedures.

    Bookmark   June 7, 2004 at 9:01AM
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My dentist does this all the time. Our insurance statement shows what was charged, how much they will pay for that procedure and our normal copay. Then we still have to pay the difference between what they cover and what he charges.
Apparently there are 2 levels of participation. One is where the dentist agrees to accept the amount the insurance company chooses as the full payment for each procedure. The other is where the dentist accepts insurance payments from that company, but does not agree to limit his fee to their payment schedule. He/she is allowed to do that, at least in my state.

    Bookmark   June 9, 2004 at 11:50AM
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Interesting thread....I just had this topic come up in a committee meeting at work. (I work at a healthcare association.) As others have said, patients are ultimately responsible for the bill, regardless of what insurance pays. Too often a patient--an I know I am guilty of this--figures that payment is an issue between the insurer and provider. Some dentists do not hold their patients feet to the fire, so to speak, when a claim is denied or reduced. Instead, they pursue the insurance company. However, a dentist is within his or her rights to request the patient to pay the difference between what insurance pays and what he or she charges.

I think someone implied that this is an issue only for dental plans. Not so, at least in my experience. I can recall a handful of times when I had to pay the difference for tests or treatment prescribed by my primary care doctor.

    Bookmark   June 23, 2004 at 10:03PM
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Sully6 is correct that this can happen with medical insurance as well. I wanted to point out one exception. If the patient has Medicare, and goes to a provider that participates with Medicare, then the provider must accept the amount that Medicare decrees the procedure is worth. The Medicare Explaination Of Benefits letter that the patient receives clearly states the amount of copay the patient is expected to pay. It also states that the provider is not allowed to charge more than that copay.

Some health care plans also treat providers that way, not allowing their participating providers to charge more than the agreed-upon amount. Some insurers allow patients to use their insurance at nonparticipating providers and those providers can charge the patient more if they want to.

When you think about it, medical care is about the only service you get that not only does not tell you ahead of time what the costs will be, but often CANNOT tell you ahead of time what the costs will be! Different insurers pay different amounts for the same service, and different contracts within that insurer's contracts with employers have different deductibles and copays. It is almost impossible sometimes for the office staff at our counseling office to tell me what my clients will have to pay for their meetings with me. Sometimes when you call the insurers you do not get the same answers twice in a row.

    Bookmark   June 24, 2004 at 10:40AM
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We have 2 dental insurance plans. It USED to be that when we had dental work done, the dentist sent everything into the primary insurer and they paid their portion, then the remaining would be sent to the secondary provider, who would then pay the remainder.
Well, now they have "co-ordinated" benefits and only one insurer pays! What a crock!
Kathy G in MI

    Bookmark   June 26, 2004 at 10:43AM
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