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Can a dentist charge more than the Estimate of Benefits provided after services were rendered?

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BethG66

New member
I live in VA but this occurred in FL. I visited a dentist with tooth pain and they told me that my remaining teeth had to be removed and I needed dentures. This was during an extremely stressful time period and, looking back, I should have gotten a second opinion but I was in no condition at the time to think to do so. I was asked to sign a proposed treatment plan, which is not unusual to me. My expectation was that the dentist would be contacting Delta Dental to establish the contracted rates and that those amounts would be used as my final charges. I never signed anything stating that I would accept any rates other than those contracted with my insurance company. Instead, I found myself being charged 'discounted' rates that were higher than what the Explanations of Benefits forms listed, by about $1,000. The office manager refused to balance my account against the Explanations of Benefits with no reason given other than 'you signed the treatment plan'. I contacted Delta Dental's grievance department, I also reached out to my HR department. I am aware of Delta contacting the provider office manager on 2 occasions but I am still being refused the contracted rates. I have also requested copies of my records via certified mail, that request was ignored. I have asked for an account ledger and have received nothing. Should I forget about my $1000 and just walk away? As an example, I was charged a 'discounted rate' of $200 per extraction instead of the contracted rate of $136 with me paying 20% and Delta paying 80%. Delta paid the full amount of the annual policy. Delta Dental refuses to do anything further on my behalf to try to get my $ back from the provider.
 


Just Blue

Senior Member
I live in VA but this occurred in FL. I visited a dentist with tooth pain and they told me that my remaining teeth had to be removed and I needed dentures. This was during an extremely stressful time period and, looking back, I should have gotten a second opinion but I was in no condition at the time to think to do so. I was asked to sign a proposed treatment plan, which is not unusual to me. My expectation was that the dentist would be contacting Delta Dental to establish the contracted rates and that those amounts would be used as my final charges. I never signed anything stating that I would accept any rates other than those contracted with my insurance company. Instead, I found myself being charged 'discounted' rates that were higher than what the Explanations of Benefits forms listed, by about $1,000. The office manager refused to balance my account against the Explanations of Benefits with no reason given other than 'you signed the treatment plan'. I contacted Delta Dental's grievance department, I also reached out to my HR department. I am aware of Delta contacting the provider office manager on 2 occasions but I am still being refused the contracted rates. I have also requested copies of my records via certified mail, that request was ignored. I have asked for an account ledger and have received nothing. Should I forget about my $1000 and just walk away? As an example, I was charged a 'discounted rate' of $200 per extraction instead of the contracted rate of $136 with me paying 20% and Delta paying 80%. Delta paid the full amount of the annual policy. Delta Dental refuses to do anything further on my behalf to try to get my $ back from the provider.
When did this happen?
 

quincy

Senior Member
I live in VA but this occurred in FL. I visited a dentist with tooth pain and they told me that my remaining teeth had to be removed and I needed dentures. This was during an extremely stressful time period and, looking back, I should have gotten a second opinion but I was in no condition at the time to think to do so. I was asked to sign a proposed treatment plan, which is not unusual to me. My expectation was that the dentist would be contacting Delta Dental to establish the contracted rates and that those amounts would be used as my final charges. I never signed anything stating that I would accept any rates other than those contracted with my insurance company. Instead, I found myself being charged 'discounted' rates that were higher than what the Explanations of Benefits forms listed, by about $1,000. The office manager refused to balance my account against the Explanations of Benefits with no reason given other than 'you signed the treatment plan'. I contacted Delta Dental's grievance department, I also reached out to my HR department. I am aware of Delta contacting the provider office manager on 2 occasions but I am still being refused the contracted rates. I have also requested copies of my records via certified mail, that request was ignored. I have asked for an account ledger and have received nothing. Should I forget about my $1000 and just walk away? As an example, I was charged a 'discounted rate' of $200 per extraction instead of the contracted rate of $136 with me paying 20% and Delta paying 80%. Delta paid the full amount of the annual policy. Delta Dental refuses to do anything further on my behalf to try to get my $ back from the provider.
You might be out of luck if you signed the treatment plan.
 

Taxing Matters

Overtaxed Member
My expectation was that the dentist would be contacting Delta Dental to establish the contracted rates and that those amounts would be used as my final charges.
Why did you have that expectation? Was this dentist a preferred provider (PPO) for Delta? Did you check that before going to this dentist? It's important to understand that there is a huge difference between a provider accepting a particular insurance plan and being a PPO for the plan. The former just means that they'll bill the insurer before billing you — you are typically responsible for the difference between the provider's rates and what the insurance company pays. The provider in that instance is not obligated to accepted the rates established by the insurer for the work. A PPO on the other hand has contracted with the insurer to accept the limits on charges for various procedures and thus can only collect from you what the insurer says is your obligation under the insurance plan. That's what you see in your explanation of benefits (EOB); the amount you're responsible for if the provider was PPO.

I never signed anything stating that I would accept any rates other than those contracted with my insurance company.
You signed the treatment plan and it almost certainly referred to the rates that would be charged. Unless the contract specifically said that the insurer would accept the insurance company's limit on charges or the provider is a PPO (in which case that is implied in the contract even if not specifically stated) you are responsible for the full amount of charges per the contract. Look at it and quote here exactly what it says about the cost for the work (without using any names or other identifying information for the provider) and we may have some comments about whether that limits the provider to accepting just the insurance company's established rates for the procedure. Or have a local attorney look it over.

Instead, I found myself being charged 'discounted' rates that were higher than what the Explanations of Benefits forms listed, by about $1,000.
That happens a lot when the provider is not a PPO.
 

BethG66

New member
This provider is listed as a PPO for Delta. The very top line says 'Proposed Treatment Plan' and I had to initial it. I have done the same with my dentist back in VA many times, also a PPO, and had no issues.
 

BethG66

New member
Delta says they should charge me per the contracted rates, they even called the provider 2 times and explained to them how to balance the account against the Explanations of Benefits. I have no clue why they refuse to do anything further, the provider is still a PPO for them.
 

Zigner

Senior Member, Non-Attorney
To my knowledge, ALL hospitals (outside of military hospitals, and even sometimes them) only work for money (most of the time).
 

Zigner

Senior Member, Non-Attorney
Even poor patients are provided medical care.
Yes, but rarely is that care free. It may be at no cost to the patient, but the hospital gets paid. I'm sure there may be some exceptions, but they are definitely exceptions and not the norm.
 

quincy

Senior Member
It was ayankristy’s “only money, I saw, some of the hospitals are first given preference to the patient only but this number is less” that had me confused, especially since this is a thread about dental insurance.

I am thinking spam seed. :)
 

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