Any dentists or insurance experts here?

#1
CanadianVol

CanadianVol

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#1
My wife got retainers this summer and the orthodontist said it would be covered 50% by insurance. Now the insurance company is saying it's not covered and the orthodontist is sending our account to collections because we haven't paid a bill we didn't know about before Saturday. Needless to say I'm pretty livid. Any idea what I can do that doesn't involve paying the huge bill?
 
#2
#2
You have no way to know what exactly your insurance covers? Usually your mailed a copy of the policy that has a coverage chart or at least have access to view what it covers online. Most dental insurance has a yearly max regardless of the percentage it covers & orthodontia usually has a max & will eat up most of it if used.
 
#3
#3
I own an insurance agency and have been working in the insurance industry for a little bit.

Do you know who informed you on behalf of the company that they covered 50%? That's a binding verbal contract.

On your dental policy does it specify a list of co-payments or shared expenses in which a list of services is provided documenting the percentage paid by the insurer or out of pocket?

If someone told you they would pay it then the company needs to make sure this situation is indemnified, and you are paid 50% of the cost.
 
#5
#5
Most dental plans don't cover adult orthodontics, do they? I know they cover children/dependents, but I don't know of any that cover orthodontics for adults.
 
#7
#7
If the insurance company won't do anything, you can negotiate the bill. If the orthodontist still has the bill, then most will accept an upfront lump sum percentage to cover it. Insurance companies don't pay the entire amount either. If it is out of the orthodontist's hands and truly with a collection company, they will take partial payment, too. Collection companies pay pennies on the dollar to take accounts hoping to get money. I would offer no more than 50-60% of the entire bill and pay it off. This is from the legal side and not the insurance side. That is where my experience comes from.
 
#8
#8
Out policy says it covers 50% of orthodontics. Just a blanket grouping. When I called they said they only cover retainers after braces, not just retainers. I think I'm getting screwed, but don't know how to resolve this reasonably. I feel like the orthodontist office shouldn't have told me it would be covered if they didn't know. They claim it was "just a quote".
 
#9
#9
CanadianVol said:
Out policy says it covers 50% of orthodontics. Just a blanket grouping. When I called they said they only cover retainers after braces, not just retainers. I think I'm getting screwed, but don't know how to resolve this reasonably. I feel like the orthodontist office shouldn't have told me it would be covered if they didn't know. They claim it was "just a quote".
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Uh, I think a quote is the price and offer they are legally obliged to stick with once you agree to it as long as no variations to the quote were made.
 
#11
#11
CanadianVol said:
Out policy says it covers 50% of orthodontics. Just a blanket grouping. When I called they said they only cover retainers after braces, not just retainers. I think I'm getting screwed, but don't know how to resolve this reasonably. I feel like the orthodontist office shouldn't have told me it would be covered if they didn't know. They claim it was "just a quote".
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I'm sure the insurance company probably considers it a cosmetic procedure which is usually limited or not covered on a dental plan. The Dentist's position, no doubt, is that you're responsible for your insurance benefits, but no way should they be quoting prices that make assumptions about your insurance coverage without getting preapproval or making it clear that you should verify coverage. That's unprofessional and bordering on unethical.

If you were never billed before being sent to collections, you've got an issue there too.
 
#12
#12
GAVol said:
I'm sure the insurance company probably considers it a cosmetic procedure which is usually limited or not covered on a dental plan. The Dentist's position, no doubt, is that you're responsible for your insurance benefits, but no way should they be quoting prices that make assumptions about your insurance coverage without getting preapproval or making it clear that you should verify coverage. That's unprofessional and bordering on unethical.

If you were never billed before being sent to collections, you've got an issue there too.
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Bingo.

the dentist and even the insurance co will probably use the defense that its your responsibility to know if something is covered or not, not the dentist or insurance. True, but that being usually a dentist office might "quote" you the price but in my experience have always said they will have to run it by insurance first to be sure its covered. They do it as a courtesy. Kinda sounds like they are trying to skip the nice part and go straight for the money. Pretty bad cust retention.

In the end you'll probably be on the line for payment but nothing a nice little write up on Yelp or some facebook page for that area of town to warn others of their practice.
 
#17
#17
Returning it wont do any good. It's not like buying a tent from Wal Mart, never using it, and taking it back. Retainers are custom fitted.

As for the insurance side of things, most policies are written to exclude cosmetic work unless there is an endorsement to the declaration page. You would have paid for said endorsement. Unfortunately, you're contractually obligated to comply with the conditions and terms written on that page. You're also contractually obligated to pay your ortho bill if you signed anything, which includes a release to perform any type of preliminary procedure, such as xrays, molds, ect...

The ortho office has also created an issue for themselves due to them not confirming the policy coverage would be applicable to this situation. Keep in mind that they too have multiple policies in place in order to practice their trade. One of which in Pro Liability with an E&O Clause specifically written in for these types of mistakes.

Contact your dental insurance provider and ask to see the policy dec page along with the list of exclusions and endorsements. Should you find the devil in the details there, you'll know whether or not you have ground to stand on.

As for the collections company, you have a window of roughly 30 days in most states before they ever pursue you in a manner that creates discomfort. A second notice is mailed via US Postal, which provides an additional 5-7 days. Considering you they use a national brand entity, you'll be one of thousands and small fries such as a retainer would be low on the pecking order.

I'm in insurance so take it for what its worth. Good luck.
 
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#18
#18
TXA&M07 said:
Returning it wont do any good. It's not like buying a tent from Wal Mart, never using it, and taking it back. Retainers are custom fitted.

As for the insurance side of things, most policies are written to exclude cosmetic work unless there is an endorsement to the declaration page. You would have paid for said endorsement. Unfortunately, you're contractually obligated to comply with the conditions and terms written on that page. You're also contractually obligated to pay your ortho bill if you signed anything, which includes a release to perform any type of preliminary procedure, such as xrays, molds, ect...

The ortho office has also created an issue for themselves due to them not confirming the policy coverage would be applicable to this situation. Keep in mind that they too have multiple policies in place in order to practice their trade. One of which in Pro Liability with an E&O Clause specifically written in for these types of mistakes.

Contact your dental insurance provider and ask to see the policy dec page along with the list of exclusions and endorsements. Should you find the devil in the details there, you'll know whether or not you have ground to stand on.

As for the collections company, you have a window of roughly 30 days in most states before they ever pursue you in a manner that creates discomfort. A second notice is mailed via US Postal, which provides an additional 5-7 days. Considering you they use a national brand entity, you'll be one of thousands and small fries such as a retainer would be low on the pecking order.

I'm in insurance so take it for what its worth. Good luck.
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So are you saying that the Ortho should have a policy to cover their stupidity? I really don't think they actually checked with the company, I think they just pulled up my plan and saw the 50% coverage, same as I did.
 
#19
#19
I provide mgmt services for health care clinics. Our clinics are instructed to use an insurance coverage verificatiin form. It documents who they spoke with and the benefits and policy limitations. unfortunately, much of the verification is now either automated or online. There isnt a live person to be on the hook when benefits differ from what was verified.

I would ask the office what their verification process is. They should be able to provide internal paperwork/software pages, a website or an automated number where they verified your benefits. If they cannot, i would talk to the owner and office manager explaining what occured. If i managed that clinic, i would write off your balance and do training with staff or fire the incompetent people.
 
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#20
#20
CanadianVol said:
So are you saying that the Ortho should have a policy to cover their stupidity? I really don't think they actually checked with the company, I think they just pulled up my plan and saw the 50% coverage, same as I did.
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I'm absolutely telling you they have to have a policy in place. It's not a matter of "they should" or not.
 
#21
#21
So, I got my plan documents. This is what they say for Orthodontic work:

All of the following conditions must be met in order for an orthodontia charge to be considered an eligible charge for benefit payment:
• The charge is for a service or supply provided to a covered person in connection with an orthodontic procedure before the end of the estimated duration shown in the orthodontic treatment plan. See Orthodontia Pretreatment Review for the definition of an orthodontic treatment plan. The Plan will cover the charges of one course of orthodontia treatment per
covered individual as outlined in the orthodontic treatment plan
• An active appliance for the orthodontic procedure is inserted while the person is a covered person for Plan benefits. An orthodontic procedure is the use of active appliances to move teeth to correct faulty position of teeth (malposition) or abnormal bite (malocclusion)
• The orthodontic procedure is needed to correct one of these conditions:
• Vertical or horizontal overlap of upper teeth over lower teeth (over-bite or overjet)
• Faulty alignment (either frontward or backwards) of the upper and lower arches with each other
• Cross-bite
• The service or supply is made part of an orthodontic treatment plan that, before the orthodontic procedure is performed, has been:
• Sent to MetLife for review
• Returned by MetLife to the dentist showing estimated benefits

Anything here that sticks out that can support us? The last section stuck to me ,as we were never provide a treatment plan or anything like that.
 
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#22
#22
"The charge is for a service or supply provided to a covered person"

"Supply" is the retainer. Everything is else just definitions of what classifies orthodontic work.
 
#24
#24
TXA&M07 said:
& Met Life should have been contacted for their approval.
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They way it reads combined with the trouble OP is experiencing makes it seem as if the dental office could have coded the appliance incorrectly, right? It looks like coverage is there as long as it has been pre approved and it is to correct the conditions listed.
 
#25
#25
McDad said:
They way it reads combined with the trouble OP is experiencing makes it seem as if the dental office could have coded the appliance incorrectly, right? It looks like coverage is there as long as it has been pre approved and it is to correct the conditions listed.
Click to expand...

You're reading appliance as a noun. It's a verb in this situation. Insurance legal jargon is not always what it seems.
 
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