How dentists bill insurance

whisperyOctober 23, 2003

Hi- I'm really hoping someone with experience in dentistry billing can help me with this. Bear with me as I try to explain it.

My husband and I have a pretax flex account that pays us back for qualified medical expenses, including dental. In order to be reimbursed, I have to provide the flex account people with an Explanation of Benefits from my insurance company. This document shows how much my health care provider billed the insurance company for, how much the insurance company paid the provider, and the difference- which is what I pay and the flex account people reimburse me.

I'm looking back over my health care paperwork for the last year, trying to find expenses I haven't submitted and been reimbursed for. I noticed a dental expense I had submitted was denied because I had only sent the flex account people a copy of my credit card receipt, not an Explanantion of Benefits. So I went back to the Explanantion of Benefits documents I have on file and they all say that for every claim my dentist made to my dental insurance, they were paid the full amount. So the paperwork shows that I never owed/paid my dentist any money. Yet I have receipts showing that I paid my dentist over $400 this year.

I THINK what happened (but I don't KNOW) is that the dentist asked me to just pay outright the portion they expected the insurance to deny, and only submitted to the insurance what they knew would be paid. Do you think that is the case? Why do you think they did it that way?

How this affects me is that I don't have an Explanation of Benefits that indicates that I paid anything to my dentist. And only that document will be accepted by the flex account people in order to prove there was an expense they can reimburse me for.

I know I need to go talk to my dentist's office and ask them why they billed as they did. Unfortunately, I am not on good terms with that dentist. Despite the fact that I am a generally agreeable person, I walked out of my last appointment because I wasn't comfortable with the way he was handling my appointment. My husband did offer to pay as I was waiting in the car, so we did not stiff them.

If I go into that dentist's office now, I am not convinced that they will be clear or honest with me. So I feel like I need to understand as much as I can about this situation before I go in so that it is more likely I will have good results from the conversation I have with them.

Can anyone with experience in the dental field help me understand why my dentist's office did the billing as they did?

Thank you very much,


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If the dentist settled for the amount that the insurance company would pay him as payment in full, you are not any money out of pocket.

So it appears to me that your carrier owes you nothing.

Tell me if I'm wrong.

joyful guy

    Bookmark   October 27, 2003 at 2:30AM
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There are sometimes confusing situations if you went to a non-participating (with your particular insurance plan)dentist. A plan will pay up to a MAC/maximun allowable charge for a given procedure. Some times that plan will not pay the MAC to a non-participating dentist, occasionally (not usually) the plan will pay MORE to a non-paticipating dentist. If you went to a non-participating dentist, his charge may have been higher than what your insurer has set as its MAC fo a given procedure. In this situation, the dentist has the right to charge his own fee, your insurer pays a portion and you would pay the balance. Normally, the dentist would bill the insurer for his fee, not the MAC, and would be paid by the insurer only the amount for the MAC, or sometimes another amount, either higher or lower than the MAC, depending on the insurer's rules. If you went to a non-participating dentist, you are responsible for whatever portion remains after the insurer has paid.
It would be unlikely that the dentist would bill the insurer only for that amount they know that would be paid; ie: the MAC, because your ledger (record of all charges, kept by the dentist) would not reflect what you owed. It is more usual for the dentist to bill out the normal fee to both the patient and the insurer, send in to the isurer for that amount, and ask for the balance from the patient at the time of service. This amount is usually an estimated amount, based on previous experience by the office with reimbursements from that insurer.
There is also the possibility of an embezzelment situation by an employee of the dentist, where the employee asks for payment above what is actually due.
The best advice is to ask for a copy of your ledger to see what charges were billed, what you paid, and what the insurer paid. You may be pleasantly surprised to see a credit in your account with the dentist for all that extra $ you paid out. When submitting for flex acct reimbursement, you need to have individual statements for each date of service printed out by the dental office to coordinate with the dates of your EOB's/Expl of Benefits. This way the Flex acct people don't have to decipher the whole ledger history (too much work). Make sure to choose a participating dentist to maximize your benefits.
This, however opens up another kettle of fish, b/c many insurance plans have ridiculously low MAC's and quality dentists will not participate with those plans, b/c they pay so poorly. You would not like to go to work every day for only half of your normal paycheck. Make sure in the future you get a "Walkout" statement as well as your CC receipt from the front desk after every visit.
Just another tidbit--the dentist will probably not want to give you anything if you owe money to him. It is illegal for dentists to withold xrays, records, etc, even if you owe money. They are allowed to charge a fee for copying any records, but cannot refuse to provide them.
Hope this helps you out--

    Bookmark   March 13, 2010 at 3:32PM
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I've had a similar thing happen. Normally, I pay my dentist in full and tell the insurance company to send me the check rather than sending it to the dentist. Sometimes the insurance co. disregards my instructions and sends the check to the dentist by mistake. When that happens, the dentist winds up getting overpaid and I wind up with a credit on my account, which we have to straighten out.

In your case, I guess you need to get an itemized statement from your dentist of all the payments the dentist has received from your insurance company, and a similar statement from the insurance company. If the two statements match, you should be in the clear. If not, you can give each one a copy of the other's statement and say "Please work this out between yourselves; it shouldn't be my problem."

    Bookmark   March 13, 2010 at 10:37PM
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The OP was seeking advice in 2003.


I think a record has just been set for the oldest thread brought back to life! ;-)

    Bookmark   March 14, 2010 at 12:36AM
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This is odd, because this thread was resurrected recently, and I swear I replied. Unless the OP posted nearly the same thing twice. Maybe some GW glitch? Odd!

    Bookmark   March 15, 2010 at 1:16PM
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