Friday, May 21, 2010

What is the premium my dental plan will cover?

How do I find out the difference I'd have to pay my dentist with my insurance. What are things to consider when using my insurance, will the doctor charge the insurance more than if I paid in cash?

So far I paid in cash for two root canals and paid $450 per each one but the insurance game me a number of $560. Did the doctor charge me less because I paid in cash? This doctor is in-network.

What is the premium my dental plan will cover?
Your dentist should give you a treatment plan after they have submitted and received the pre-determination from your insurance co. This will tell you what the dentist charges, what your insurance will pay and what part of the balance is your responsibility.

Whether they give a break for people who pay cash is up to each individual office and how they like to run their business. We treat clergy for free, if that is unethical, than so be it. We also give breaks to large families, friends and colleagues. Sometimes we won't charge depending on the procedure that was done.

Root canals in our area can range from approx. $650-$800 for an anterior tooth, $800-$1000 for a bicuspid (two roots), and $1000-$1250 for a molar root canal. Most insurance plans will pay approx 80% of a root canal, but it also depends on what your insurance co. considers "reasonable and customary" which means, Dr. A could charge $800 for a root canal but the insurance co. only allows $500.00 for that tooth, so they will pay 80% of the $500.00.(not the $800 charged)

Also, a root canal is one of those procedures that does NOT require a predetermination, mostly because patients can't wait one month before having a root canal because they are in pain.

Ask for a treatment plan of all the work you need to have done, and including insurance estimates. This will give you a better idea of what is really charged and what you owe, and what your insurance co. will pay.
Reply:Most doctors no matter what their specialty, will charge cash paying patients less. They do this because they want you to keep returning to them, and to give you a break on expenses. They usually discount by how much they would normally get from insurance anyway. So your example of the $560 charge, docotors are paid a fee schedule, or a certain amount by an insurance company. Barely ever will an insurance pay the whole charge. They usually payout at 80% and the fees go down from there after each additional charge to about 35%.

This is why the doc probably charged you that amount, but trust me it's worth to go through your insurance, as they will end up picking up the most of the tab 90% of the time.
Reply:The best way to find out what your financial obligation will be for dental treatment is to have a pre-treatment estimate(pre-authorization) completed. Your dentist will file his fees for the procedures and the insurance company will report back what they will cover (your benefit) and what you will owe(your co-insurance) I hope that your dentist doesn't use different fee schedules based on insurance coverage, as that is both unethical and in violation of the dental practice acts in most states.
Reply:You should be able to get a good idea from the business office before you do a procedure. They have your info and can figure out what to expect and what you should expect to cover. Sometimes if you don't have a lot of coverage they can lower some of the charges for like administrative fees.
Reply:Contact the benefits department within your work place or your dental insurance company. There are tons of dental insurance as well as health ins. but I am sure you were aware of this otherwise you would not have ask this on here?
Reply:Your insurance will have a fee for each procedure that your dentist would do on you. This is called a usual and customary fee. The dentist can't charge you anymore than this fee, since he is in-network. They insurance will then pay their percentages off of this fee, such as 100% preventative, 80% basic (including root canals), and 50 % major.

Your copay on each rootcanal seems to be too high. $450 is not 20% of a rootcanal. What is the percentage on your plan for a rootcanal? You also need to find out your insurance companies Usual and customary fee. If you do this, you can find out exactly how much you would be paying each procedure.

The insurance company shouldn't get charged differently than what you get charged. That is insurance fraud. What is on the claim, is the amount they charged you. They can't put one amount on the claim and quote you another fee. This has nothing to do with your copay. You would owe a copay regardless. What I am saying, is they can't submit a claim saying they charged you $600 for a rootcanal, if they in fact only charged you $400. Just an example, but you see what I mean.

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