Dental Insurance Question

[mrodgers]

It may have been part of their contract with the Dentist. So what can the insurance company do if a Dentist discloses that information in violation of the contract? Sue them for breach of contract. As the Judge said in Jury instructions on the law in a trial I was on the Jury for.........."something can be ethically wrong, but required by law"......in this case, a contract with the Dentist.

What contract if the insurance no longer accepts them or they no longer accept the insurance? The insurance doesn't cover said doctor, they have nothing that prevents the doctor from telling the patient as far as I see.

And the "The insurance company forbid us from talking to their patients." part, insurance companies don't have patients, they have clients and in no way has any bearing on what medical service who doesn't accept said insurance tells their patients.

 

[Princesca]

I have had some luck getting charges filed as in-network when providers were not in-network and I wasn't informed. Once was an anesthesiologist; it's just ridiculous that hospitals can't tell you who you will have and once you're on the table after pre-op you're not going to be like 'Oh sorry, you aren't in network, I have to go.' So it's pretty common to argue those and get them refiled. I also had luck in another instance where the office was in network but the provider I saw was not. Point is, you can sometimes make the argument and have some luck getting it adjusted.

 

[Mackenzie Click-Mickelson]

I have had some luck getting charges filed as in-network when providers were not in-network and I wasn't informed. Once was an anesthesiologist; it's just ridiculous that hospitals can't tell you who you will have and once you're on the table after pre-op you're not going to be like 'Oh sorry, you aren't in network, I have to go.' So it's pretty common to argue those and get them refiled. I also had luck in another instance where the office was in network but the provider I saw was not. Point is, you can sometimes make the argument and have some luck getting it adjusted.

That's a bit different though. In those medical procedures you had every intention of an in-network but so and so wasn't available or something like that. That's way different (and is something laws have been trying to correct) than a dentist who was in-network but no longer was.

What you're talking about is going into a surgery in a hospital in an in-network facility but the anesthesiologist who did your particular surgery was not in-network and you didn't know that. What the OP is talking about is their dentist practice is no longer in-network.

 

[Princesca]

What you're talking about is going into a surgery in a hospital in an in-network facility but the anesthesiologist who did your particular surgery was not in-network and you didn't know that. What the OP is talking about is their dentist practice is no longer in-network.

Yes, but I'm saying I think the OP should have been told and there may be SOME recourse through either the provider or the insurance. I have had luck more times that those, those were just two from the past couple of years. It's worth a try anyway.

And for that provider, I don't know. I don't see how an insurer can forbid them not to say anything, especially when that provider is no longer part of their network? What hold can they have over them? It should be at least mentioned in conversation, or jeez, even a 'Hey, have you checked your insurance network coverage lately? HINT HINT.' I would have a serious beef over this.

 

[tzolkin]

I would say you were making an informed decision already because you were told after your son's procedure they were out of network but you continued to go back for cleanings not once but three times between y'all. This isn't to mean you wouldn't have wanted to know before your son's gum graft but that you were informed and still went to the existing practice. If that procedure was $2300 and you owe $2800 this means you incurred excess costs knowingly.

I read that portion as they had already gone twice for cleanings before they received the bill for the son's procedure and realized that the dentist was no longer accepting their insurance. Not that they knew and continued to go. I may be wrong, but if that's the case it makes it even worse to me because it wasn't a one-time thing where they didn't tell them that the insurance agreement had changed, but instead let them come in multiple times and rack up bills without being aware of the situation.

I think it's up to the patient to check if a doctor or dentist is in or out of network. And that's done by calling the insurance yourself, not the place providing the service(s).

This is probably what people should be doing, but I don't think most people will realistically call their insurance company prior to every single appointment that any member of their family has just to verify that their doctor is still in-network.

That's a bit different though. In those medical procedures you had every intention of an in-network but so and so wasn't available or something like that. That's way different (and is something laws have been trying to correct) than a dentist who was in-network but no longer was.

What you're talking about is going into a surgery in a hospital in an in-network facility but the anesthesiologist who did your particular surgery was not in-network and you didn't know that. What the OP is talking about is their dentist practice is no longer in-network.

Absolutely. I manage an anesthesia company. Our billing company automatically adjusts patients' bills to charge the in-network amounts and we waive bills all the time when it's something that the patient was not expecting because they weren't properly informed of the anesthesia costs. That is the complete opposite of what this dentist did. They knew the patient's insurance would not cover the procedure and then did it anyway without telling them. They are probably making even more money, because the price that the cash-pay/no insurance patient pays is usually significantly more than what their agreed upon amount with the insurance company had been.

 

[RUDisney]

I work in procurement. I can tell you that EVERYTHING is negotiable.

In good faith, I selected a doctor and hospital for a colonoscopy a few years ago. Everything was covered, but I got a bill for an exorbitant amount from the anesthesiologist. I had a decision to make. I decided to call the insurance company to file a complaint. That was as far as it went and I never received another bill.

Had I received another bill, I would have called the provider and said, "what is the realistic charge for this service, because I'm not paying the total amount. What would a carrier that you are in network with pay for it?" Start there, and negotiate from there, knowing what the high cost is. Remember, if a doctor is charging $2,500 for a service, the insurance company is probably paying a fraction of that. Just look at your EOBs to see the difference in what the doctor wants and what it gets.

Once I had a number that I thought was fair, I'd pay the doctor in $25-$100 increments until it was paid off.

That being said, I feel for you. The dentist showed his true colors. I wouldn't want to use him anymore. Find out who is in network and ask your friends for referrals. You want a new dentist who isn't "cavity happy." I went to a dentist a while ago who found a cavity every time I went to him. I had never had a cavity before. Since I left him, I haven't had a cavity since. Gosh, how does that happen? Turns out this guy became famous quickly for telling everyone that they had cavities. How would us "average" folks know for sure?

 

[Mackenzie Click-Mickelson]

It's worth a try anyway.

Sure and I'm usually about no harm no foul in asking and the OP can def. do that, why not ya know. I'm just saying different industries have different things going on. Eye insurance (which often is like a discount plan) works differently than dental and dental works differently than normal health insurance.

I can go online with my health insurance provider and select only in-network to see which locations are like that. But you can't account for one person on your surgery team not being in-network so I totally get pushing back against the insurance for that reason. The new law regarding surprise medical bills is more what I was talking about in my prior comment about laws trying to change that. But that is related to health insurance, not the dentistry industry.

An example that directly relates to your first comment is shown on a government page. It goes like this "

• Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at an in-network facility."

Because yes as you put it you're not going to duck out when you're laying on the operating table due to an out-of-network anesthesiologist.

 

[Mackenzie Click-Mickelson]

I read that portion as they had already gone twice for cleanings before they received the bill for the son's procedure and realized that the dentist was no longer accepting their insurance. Not that they knew and continued to go. I may be wrong, but if that's the case it makes it even worse to me because it wasn't a one-time thing where they didn't tell them that the insurance agreement had changed, but instead let them come in multiple times and rack up bills without being aware of the situation.

You're right it's actually ambiguous to me at least when I re-read it.

They mentioned getting a check last month, then calling the dentist office who said 1/1/22 no longer in-network. Then they said when they booked the son's gum graft they were not verbally told they were/would be out-of-network now (don't know when they scheduled the son's procedure) and the son's procedure was done in February. The next sentence was since then they had all gone in for cleanings. So you're right it's not entirely clear whether the cleanings occurred after the OP got the check last month prompting the call to the dentist about it or in between when the son's procedure had been booked and last month when the OP talked with the dentist.

This is probably what people should be doing, but I don't think most people will realistically call their insurance company prior to every single appointment that any member of their family has just to verify that their doctor is still in-network.

I def. don't think we do it every time even though yeah we probably should.

What I will say is I have always been able to look online to see if my insurance (health or dental) is accepted at this place or that place.

I also just looked at my eye care's website and it does list the insurances they accept but advises they accept ones not listed so call to ask for that. Granted I only see my eye doctor once per year but when I call to make an appointment they do verify that I still have the same insurance. I've only had two companies for eye (VSP and EyeMed) but I have had to notify them when I've switched and in fact the next time I go in I will need to do that before my appointment is actually made that the insurance has switched from VSP to EyeMed due to my husband switching jobs.

While I do think it's ultimately our responsibility to many of us there's not a reasonable reason for us to suspect that a place we habitually go to is suddenly not in-network and I think that's where we're all on the same page here

 

[tvguy]

What contract if the insurance no longer accepts them or they no longer accept the insurance? The insurance doesn't cover said doctor, they have nothing that prevents the doctor from telling the patient as far as I see.

And the "The insurance company forbid us from talking to their patients." part, insurance companies don't have patients, they have clients and in no way has any bearing on what medical service who doesn't accept said insurance tells their patients.

Non-disclosure clauses are not uncommon in contracts. Usually with a specific time frame, like six months and with specific damages spelled out if violated..

 

[princesscinderella]

It sounds like bad practice management. Unfortunately dental insurance doesn’t work like medical insurance and most dental insurances pay the same $1000 in benefits they have since the 80s with discounted cleanings and fillings. That said everyone who comes to our dental office (perio) receives a printed treatment plan with the estimated insurance benefits so there’s no surprises. We will also do a predetermination if there’s questions as to coverage of a particular procedure. A general dental office runs a bit less formal but they should still be able to generate a treatment plan estimate for you if they are providing more than basic dental maintenance procedures. Unfortunately dentists are not provided much education in practice management while in dental school and some offices are a mess in this area and others are well run.

 

[Lilsia]

I don't know how an insurance company can forbid anyone from telling their patients that they are no longer under contract with them. I know the burden is on the consumer but who goes in every time and asks if their provider is still under contract with their insurance? I would be angry at the dentist's office also. They provided the service knowing that your insurance did not cover it. I hate how people always blame the consumer when they are being defrauded.

 

[longboard55]

It is impossible for an individual to understand all these insurance plans. I really think it should be up to the doctor to determine what the coverage is before they start.

 

[Kellydelly]

My dentist gives us a treatment plan with the costs and insurance coverage before we have anything done outside a regular cleaning. I thought that was standard practice. I think your Dentist was shady (total bs about them not being allowed to inform you you were no longer covered), and even if you should technically make sure you have coverage for things being done, since you just had the same thing done for your husband a few months previous I also would not have thought there would be any insurance coverage issues. I would definately not pay the full bill. I would not pay the cleaning bills either. Your dentist should write it off and just charge you your regular copay. No way would I be paying her the full noncovered amount.

 

[cabanafrau]

What contract if the insurance no longer accepts them or they no longer accept the insurance? The insurance doesn't cover said doctor, they have nothing that prevents the doctor from telling the patient as far as I see.

And the "The insurance company forbid us from talking to their patients." part, insurance companies don't have patients, they have clients and in no way has any bearing on what medical service who doesn't accept said insurance tells their patients.

Non-disclosure clauses are not uncommon in contracts. Usually with a specific time frame, like six months and with specific damages spelled out if violated..

The bold above spells out why a non-disclosure clause makes zero sense in this situation.

IMO all signs point to a dentist without honesty or ethics running this practice. I'd take this as a not even extremely expensive heads up (in the world of dentistry) to seek my dental care elsewhere.

 

[tvguy]

The bold above spells out why a non-disclosure clause makes zero sense in this situation.

IMO all signs point to a dentist without honesty or ethics running this practice. I'd take this as a not even extremely expensive heads up (in the world of dentistry) to seek my dental care elsewhere.

Lots of non-disclosure clauses make no sense, but they happen.

 

[lifesavacation]

I've been getting acupuncture, which is in network. My provider was being dropped and I got several letters from the insurance company letting me know. I took one of the letters with me to my appointment and my provider didn't know anything about it. I guess she needed to upload updated credentials or something. She told me everything had gotten worked out, but I did log on to my insurance company and check so I wasn't stuck with the bill.

 

[Mackenzie Click-Mickelson]

Lots of non-disclosure clauses make no sense, but they happen.

Yeah..this really isn't a case where an NDA would be practice. Who here has ever heard of a dental insurance company forbidding disclosure of in-network vs out-of-network?

What is much more plausible is the dentist at least on certain patients did not disclose this but used a CYA type thing so as to absolve them of responsibility..."oh the insurance company wouldn't let me tell you"...yeah right.

 

[cabanafrau]

Lots of non-disclosure clauses make no sense, but they happen.

Non-disclosure agreements are contained in contracts. There is no contract between the insurance company and the dentist, therefore no clause exists. Think about it logically, not only would a prohibition like this be damaging to all dentists leaving the network who will be faced with angry patients, but it also doesn't contain ANY upside for the insurance company to require such a prohibition. Why would a dental insurer want to demand such a ridiculous provision that not only doesn't increase revenue for them, but is quite likely to increase customer dissatisfaction and may in fact cause customers to seek out a different insurance provider next year?

It's not a fluke or a matter of personal service that the dentist delivered this answer to OP personally. Kind of ironic the dentist in fact disclosed so much about themselves by attempting to hide behind a fake non-disclosure.

 

[tvguy]

Non-disclosure agreements are contained in contracts. There is no contract between the insurance company and the dentist, therefore no clause exists. Think about it logically, not only would a prohibition like this be damaging to all dentists leaving the network who will be faced with angry patients, but it also doesn't contain ANY upside for the insurance company to require such a prohibition. Why would a dental insurer want to demand such a ridiculous provision that not only doesn't increase revenue for them, but is quite likely to increase customer dissatisfaction and may in fact cause customers to seek out a different insurance provider next year?

It's not a fluke or a matter of personal service that the dentist delivered this answer to OP personally. Kind of ironic the dentist in fact disclosed so much about themselves by attempting to hide behind a fake non-disclosure.

My experience is different.

 

[tvguy]

Yeah..this really isn't a case where an NDA would be practice. Who here has ever heard of a dental insurance company forbidding disclosure of in-network vs out-of-network?

What is much more plausible is the dentist at least on certain patients did not disclose this but used a CYA type thing so as to absolve them of responsibility..."oh the insurance company wouldn't let me tell you"...yeah right.

I am caught in a situation now where I had a ceramic crown put in, and my dental insurance, as of January 1st, only pays for metal crowns. The business manager didn't know until my claim was rejected. The ceramic crown I had put in 3 weeks earlier, in December, they paid for. Go figure.