Dentist misinformed me about coverage...

[PannaNJ]

I went to the dentist to have a bad tooth looked at. I originally thought that my dental coverage was with the same company as my health care so I supplied the receptionist with my insurance card. They did a 1st time patient visit(cleaning, x-rays, etc). The receptionist said that my policy was very good and explained my coverages. It turned out that i needed a root canal and a cap, which she said the insurance would cover it at 80%, so i would have to pay about $500. We scheduled the procedure for a few weeks later and i had the procedure done(in a number of visits).
Well after it was all done, i get a letter from my health ins company saying they wont cover the dental work. I then found out at my work that we use a different company for dental. I got the correct information and supplied it to the dentist office. It turns out that my policy has a max of $1000, so anything beyond that is my responsibility. In this case that turns out to be the $500 i originally paid, PLUS an additional $1,300. As you can imagine I am rather upset with this.
How could the receptionist tell me I had coverage when i first went in, then set me up with a $3,000 procedure and then say because i gave them the wrong ins company i still have to pay it. I imagine she never really checked my policy otherwise she would have known i didnt have dental on my medical policy. Anyone have any advice?

[ecmst12]

It is YOUR responsiblity to know and understand your benefits before it is an emergency and services are needed, not your doctor's. You can't rely on someone else to do your job. You should have found out what company your coverage was with and what they covered before you even made an appointment with the dentist.

[barry1817]

Originally Posted by PannaNJ

I went to the dentist to have a bad tooth looked at. I originally thought that my dental coverage was with the same company as my health care so I supplied the receptionist with my insurance card. They did a 1st time patient visit(cleaning, x-rays, etc). The receptionist said that my policy was very good and explained my coverages. It turned out that i needed a root canal and a cap, which she said the insurance would cover it at 80%, so i would have to pay about $500. We scheduled the procedure for a few weeks later and i had the procedure done(in a number of visits).
Well after it was all done, i get a letter from my health ins company saying they wont cover the dental work. I then found out at my work that we use a different company for dental. I got the correct information and supplied it to the dentist office. It turns out that my policy has a max of $1000, so anything beyond that is my responsibility. In this case that turns out to be the $500 i originally paid, PLUS an additional $1,300. As you can imagine I am rather upset with this.
How could the receptionist tell me I had coverage when i first went in, then set me up with a $3,000 procedure and then say because i gave them the wrong ins company i still have to pay it. I imagine she never really checked my policy otherwise she would have known i didnt have dental on my medical policy. Anyone have any advice?

Did you get anything in the way of a pre-estimate prior to the treatment?
In some states that informed consent is necessary, and you should check this out with your local dental association.

As to telling you that you were covered, and then coming back that you weren't, poses an interesting problem. If the office said they checked and this is what you will pay, that is very different than if they said they are assuming that you are covered but will have to be responsible for anything not covered.

Many offices have programs that explain exactly what the insurance is and what the coverage is, so that when they give an estimate it is really pretty exact.

My response as to your action would be based on answers to previous questions.

[ecmst12]

The office called to verify coverage and were told that coverage was good. Which was true. They probably didn't ask about specific procedures or types of coverage. And regardless, it was not the office's responsibility to know what coverage was in place, it was the patient's and is ALWAYS the patient's. No mistake the office may have made removes that responsibility from the person whose name is on the policy and on the bill.

[barry1817]

Originally Posted by ecmst12

The office called to verify coverage and were told that coverage was good. Which was true. They probably didn't ask about specific procedures or types of coverage. And regardless, it was not the office's responsibility to know what coverage was in place, it was the patient's and is ALWAYS the patient's. No mistake the office may have made removes that responsibility from the person whose name is on the policy and on the bill.

I have seen too many instances where dental offices tell patients that they are covered so that they start expensive work, and when it isn't there they tell the patient that it is there problem.

Unless it is an emergency, it would be prudent to have work preauthorized so that a mutual understanding of the cost is clear. That is the reason for the informed consent prior to treatment as well as the estimate of costs.

But I have to disagree, which goes back to what are the answers to the questions previously posed. If the office said that they confirmed the coverage, and confirmed the fee that he patient needs to pay, that is very different than informing a patient that they might be covered, and would be responsible.

That also goes to the fact that if one tells a patient that the work is covered they will probably start treatment, but if they tell them that they have to check, the patient usually will say wait until the authorization is approved.

Personally I find that misleading and deceptive, and a case of a profession with more knowlegde not giving a fully informed consent.

[cbg]

Does the dentist provide the dental coverage? No. So what the dentist says is covered, or what the patient understands the dentist to say is covered, which is not always the same thing, is not binding on the insurance company.

Didn't you ever play Telephone when you were a kid? The game when a whisper goes down the line to see how different it comes out at the other end of the line?

The more people who are involved in passing the information about the coverage down the line to the patient, the more chances that the information the patient gets is not what the insurance carrier actually said. All the more reason why the patient should accept HIS responsibility and contact the insurace company directly. No matter what programs the doctor has, it is STILL the PATIENT'S responsibility and not the dentist's or doctors.

Certainly pre-authing is a good idea. But it doesn't change the basic responsibility. Which is not the doctor's.

[JustAPal00]

You misinformed the dentist as to who your insurance carrier was. Based on the incorrect information you provided, the employee explained the correct coverage information for the company that you said provided coverage, but since you mistakenly told them the wrong company it did not pertain to you. Now you feel that they "misinformed" you? Take responsibility for your mistake and pay the bill, and next time take your obligations a little more seriously!

[ecmst12]

If the patient had done her job and made sure she knew her benefits before she ever walked into the office, she never would have had to ask the office what her benefits were. Honestly, I don't care that the office may have been "misleading", though I don't think they intentionally misled anyone, they just received the wrong information. But I refuse to put any responsibility on the office here - it's just not their job.

[barry1817]

Originally Posted by cbg

Does the dentist provide the dental coverage? No. So what the dentist says is covered, or what the patient understands the dentist to say is covered, which is not always the same thing, is not binding on the insurance company.

Didn't you ever play Telephone when you were a kid? The game when a whisper goes down the line to see how different it comes out at the other end of the line?

The more people who are involved in passing the information about the coverage down the line to the patient, the more chances that the information the patient gets is not what the insurance carrier actually said. All the more reason why the patient should accept HIS responsibility and contact the insurace company directly. No matter what programs the doctor has, it is STILL the PATIENT'S responsibility and not the dentist's or doctors.

Certainly pre-authing is a good idea. But it doesn't change the basic responsibility. Which is not the doctor's.

When the dentist/office tells a patient that they have confirmed his insurance and tells the patients what the insurance will pay, it changes the dynamics of the situation. I would be more accepting if the dentist stated that they will check about coverage, but it isn't guaranteed, and if the coverage isn't proper the patient is responsible. But this wasn't the case, per the poster.

It comes very close to a bait and switch.

Again it is in the details. Don't tell the patient that they are covered, and that you don't know, puts the patient in charge, telling the patient that they are covered, that they checked, and come back with what is covered, especially when dental offices have programs that deal with these coverages is just flat out wrong.

[barry1817]

Originally Posted by JustAPal00

You misinformed the dentist as to who your insurance carrier was. Based on the incorrect information you provided, the employee explained the correct coverage information for the company that you said provided coverage, but since you mistakenly told them the wrong company it did not pertain to you. Now you feel that they "misinformed" you? Take responsibility for your mistake and pay the bill, and next time take your obligations a little more seriously!

If I give you my insurance card, and you call and verify that my insurance is good, that they cover treatment, and all is fine, who misinformed who. I know that when I was practicing if a patient came in with insurance we had the programs to check the insurance and to know exactly if the patient was covered or not. If the person's insurance wasn't listed in the program we didn't tell the patient that they were covered and that the insurance would cover treatment. We told them that we couldn't confirm and that they would be responsible if their insurance proved not to be accepted.

It is a subtle and fine distinction, but one is being honest with the patient and one isn't

[barry1817]

Originally Posted by ecmst12

If the patient had done her job and made sure she knew her benefits before she ever walked into the office, she never would have had to ask the office what her benefits were. Honestly, I don't care that the office may have been "misleading", though I don't think they intentionally misled anyone, they just received the wrong information. But I refuse to put any responsibility on the office here - it's just not their job.

I just wonder if this office even bothered to call and verify the insurance as they said. I had too many cases that when I practiced and had the insurance verified I was told they weren't covered in my office. I told the patient that.

So I have to wonder about what happened when the office called to confirm the insurance coverage, checked to see what was covered, told the patient what was covered, and then what happened when it wasn't.

I recently bought extended coverage for my car. If I were to go to a repair station for a repair that they tell me is covered, and after the repair say by the way, you aren't covered and you aren't getting your car unless you pay the full fee, I would be livid. Because the person doesn't get to misinform to their betterment.

I would have gone to another location. If they told me that they don't know if I am covered, and I go ahead that is on me.

[ecmst12]

The patient should NEVER have relied on the office to do her job for her. Period, end of sentence.

[JustAPal00]

Originally Posted by barry1817

If I give you my insurance card, and you call and verify that my insurance is good, that they cover treatment, and all is fine, who misinformed who. I know that when I was practicing if a patient came in with insurance we had the programs to check the insurance and to know exactly if the patient was covered or not. If the person's insurance wasn't listed in the program we didn't tell the patient that they were covered and that the insurance would cover treatment. We told them that we couldn't confirm and that they would be responsible if their insurance proved not to be accepted.

It is a subtle and fine distinction, but one is being honest with the patient and one isn't

BINGO!!!! The OP never said they called to verify! They have no obligation too! Now a good dentist will, but they don't have too!

[lya]

It is my understanding that the quick check done at the dentist's office is not a verification of an individual's personal policy's provisions and benefits but is a verification of the insurance company's plan's benefits.

It remains that the OP had the responsibility to know that his/her dental insurance has a $1000 per year benefit limit.