dental procedure - insurance not paying

[gianna06]

Dental Procedure Insurance Not Paying

Don't apologize you're fine. The problem with a lot of people that work for insurance companies is that they seem to accept "the average joe" to know everything about how their plans work. Not that I think you are average in way oh you know what I mean.

Okay regarding the "cheat sheet" you have if I'm understanding you correctly that is for your medical plan correct? Not your dental plan. If I am understanding you correctly then it is only for medical and the reason it doesn't separate Dental into In Network vs, Out of Network is because Medical Plans only cover dental work caused by accidents in which case a person whose been in an accident and requires immediate dental treatment is clearly in no condition to choose which provider they want to see. I ahve a strong feeling your cheat sheet doesn't separate Emergency Services either. Same rationale.

Okay now about what you listed as far as percentages and deductibles are concerned:

Deductible: $50/Individual, $150/Family
Prevent/Diagnost: 100% (no ded.)
Basic & Restorative: 80% (ded)
Major Restor: 50% (ded)
Calendar Yr Max: $2000
(then some unrelated ortho stuff)

Okay so we have determined you can go see any dentist you want. It doesn't matter if they are in or out of network. Them being in or out of network will just determine how much will be paid. Procedure Code D7230 plan pays 80% of the negotiated network fee meaning the doctor's fee is normally $300 for patients with no insurance. But if the doctor is in network both the doctor and the insurance company have agreed that the doctor will only charge patients with this insurance $250. So then the insurance company pays 80% of the $250 not 80% of the $300. Leaving the patient to pay 20% of the $250.

If the doctor is out of network then the plan will only pay up to the maximum allowable amount. Here's the catch to that, because the doctor is not in network and has no contract with the insurance company the insurance company is in no way obligated to tell the doctor what the exact dollar amount is that they will pay. So for exampe purposes lets just say that the doctors regular fee is $300 for this one procedure but the insurance company's maximum allowable for this procedure for out of network doctors is $175. The patient is responsible to pay the difference. The doctor will needed to have submitted a PTE ( Pre Treatment Estimate ) to ensure how much will be paid

All of the above is based upon already meeting your deductible but even then we can easily do the math since your deductibles are nice easy round numbers.

I'm sorry but with all of the info you have given me I hate to be the one to say this but it sounds like the insurance company is jerking you around. I'm sure you have already told me this but what is the exact reason for the denial? Is this the only procedure being denied? If your additional out of pocket cost is $245 and your deductible is only $50/$150 then you would have clearly met your deductible with this one procedure. Basic and restorative services on most plans go towards the deductible which is why I ask if you had any other services completed. Your anethesia is included in basic and restorative so that shouldn't be a problem either.

I know it's a lot of info to take in all at once but I don't mind breaking things down. Hey I saw The Rainmaker.

 

[momm2500]

dental procedure medical vs dental

the 180 days does not start from the date of service it starts from the actual date of the last correspondance from the insurance company...so you do have a little bit of time.

i will have to refer you back to the plan document. Based on what you are saying, you do not have a booklet. I would go to the employer and asked for one! when received you need to look under the medical plan listed as Covered Services. if they indicate Dental Services are covered, you then need to find what they mean by dental services. most medical plans cover accidental injury to sound natural teeth, removal of impacted teeth. you will also need to check the definition section of the medical plan on the exact wording for dental services. if it is a covered service, then you did not go to an in-network provider. if that is the case, go to the ppo website and see if there are any oral surgeons in the network near you. if not, then you have a case to appeal. some plans do have wording that is not normally listed in the plan that will allow for you to go to a doctor for treatment (who is not in the network) if you can not find one within 25 to 50 miles of your house. This is not a common provision but some plans have this.

now the dental plan, you will need to go to the exclusion section of the plan and see if it indicates that if services are covered under the medical plan, then the dental plan will not cover it.

i hate to say this, but it is not the responsibility of the dentist or oral surgeon to know your plan. they know that no matter what, that the patient is ultimately responsible for the balance. you are blessed to have a surgeon that is working with you normally they wont.

as for self funding plans, the employer has all the right in picking and choosing what they want to offer their employees. remember it is their money that is actually being paid out! yes insurance companies do offer different plans that the employer can choose; but the final line is that the employer can add and change provisions at any time. if after all appeals to the insurance company are done and no benefits are paid for, it does not hurt to go to the employer and ask if they will cover this! remember the squeeky wheel gets the oil!
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Under our Medical Benefits, "Other Medical Services and Supplies" it has a 'bullet': "Injury to or care of mouth, teeth, and gums. Charges for injury to or care of the mouth, teeth, gums and alveolar processes will be covered charges under medical benefits only if that care is for the following oral surgergical procedures." One of the things listed is "Removal of partially erupted or unerupted teeth"

There is no mention anywhere of 'impacted'. This same "removal of partially erupted or unerupted teeth" is also part of our dental benefits. Seems like a loophole to me.
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partially erupted or unerupted teeth is the same thing as partial bony or complete bony impacted teeth. This means that the teeth have not come fully through the gums and are partially or completely under the gums and are considered impacted.

i have worked for 2 of the largest insurance companies that handle both insured and self-funded plans. all oral surgeons are maxillofacial surgeons. the medical plan did not deny the claim, they did cover and give you out of network benefits which under your plan you have to meet a deductible first, then benefits are paid.

sorry i know this is not what you probably wanted to hear. but investigate the fact if there are in network providers or not in your area

 

[WonderingToo]

Gianna06: I appreciate all your feedback, I have learned a lot. Thanks so much for your time! I do feel like we're going in circles though, and I keep trying to explain the same things, and being misunderstood in return. That's ok, that happens in communication all too often, but I think at this point, after going back and forth, we might have to let it rest.
What I think I have been trying to clearly communicate is that the cheat sheet DOES include our dental benefits. We have never had a problem. Last year I had a crown done, I didn't even call our insurance company, just went to my dentist, got it done, paid my $50 plus 50% and the insurance paid the rest. Of course this was done by a dentist, and not an oral surgeon.

My problem is that our dental coverage does provide for the extraction of teeth. The wording is clear. Any insurance company cannot reasonably expect that a dentist removes wisdom teeth, as this is often done by an oral surgeon.

To Momm2500 also, I do have a booklet (it's 75 pages long, and very comprehensive). Besides the post above (I quoted from the 'cheatsheet') everything I have quoted comes from that book. I know I have written a lot, so you probably missed it, but there IS an exlcusion in our dental benefits that says if it can be considered medical, it is excluded. See my 1:26PM post from yesterday. However, the wording in the medical portion is the same as in the dental. Why would they include the same thing in the dental benefits, if the dental exlcusions rule negate it? Like the insurance guy said, it's almost like the company created a little loophole for themselves. The wording in both dental AND medical make it sound that ANY tooth extraction is considered medical. Even though tooth extractions are listed as a dental benefit, the same dental exlusion obliterates it, which I find rather odd.

I agree it is not the respon. of the surgeon to know my plans, that's why I am willing (as I should be) to pay them the remainder. I signed a document saying that I would if my insurance wouldn't pay. I feel misled however by my insurance company, who told the oral surgeon's office that the charges were indeed 50 deduct plus 20% as under the dental plan. It sounds however from wording in policies and from posts I've read on this forum, that even this verbal info from our ins. company to the surgeon doesn't mean squat when it comes to filing/decision to pay time (?).

I understand the company picks their own plan - I don't like it, but I don't complain about it. I cannot imagine how much they must have paid for us by now (I have a child with a chronic medical condition who has had 3 brain surgeries to date and is only 2), and am just grateful to have insurance even though our co-bills (20% for major medical) run into the thousands.

The total charges from the oral surgeon were 245. I paid $89 (20% plus $50 deduct). The remainder is $156, which we think our insurance should pay. I know this might sound like a little amount to some of you, but for us it's a lot, considering all the other medical bills we have.

Thanks again for your time and effort. We will send a formal letter to the insurance company, and because of what I learned from you all, I feel more confident about how I am going to word this letter. We will pay the oral surgeon in the meantime. If the insurance co. denies the claim, we might contact HR, or simply let it be.

Thanks!

 

[WonderingToo]

momm: I see you edited your post while I was typing my reply, so you can probably disregard portions of my reply. Thanks!

 

[gianna06]

Insurance Not Paying Dental Claim

Hi Wondering Too,
I'm sorry I wish I could have been more help but just as an FYI if you decide to appeal the denial and your appeal is denied then you still have the chance to appeal it again. It's called a 2nd level appeal. Just be sure to include copies of all documentation you have. NEVER and I mean NEVER send originals. Often too many times I have seen originals get "lost

If you decide to go ahead and pay the oral surgeon, there is no way for your insurance company to know unless you tell them. They will only correspond with the party that is appealing the denial. Even then it's not considered an admission of responsibility.

You would be amazed by the appeals process. It's really nothing formal. I promise you it is a group of individuals sitting around a room or on a conference call because some of the individuals are located in different states. I know this because I attend an appeals meeting once a week. Now don't get me wrong I do not have the ultimate say so or anything like that when it comes to appeals but I do contribute to the decision just as equally as the other 7 people. We read over the appeal and then look over all documents submitted and go from there. I will say this most appeals are upheld because we like to always "fall back" on "well the member is responsible for reading and knowing their benefits". As much as I cringe when that is said it's the sad cold truth of what goes on inside the walls of insurance companies.

Good Luck

 

[ecmst12]

Gianna: OP understands her benefits better then you do.