Question

How does dental deductibles work & what to do when I overpaid the office & they won't offer a refund or credit?

*My deductible is $1500. The office says I have about $600 left. What does that mean? Am I not allowed to go the dentist anymore?

*I want to get wisdom teeth pulled out but the office's quote is different from the insurance company. Insurance told me $700 but one office says $3000 & another says $1500. The office said I will be reimbursed by the ins. co. They know they will get paid but why do they ask me to pay so much upfront? I'd rather pay $700 than $3000 or $1500.

*Also, I paid both offices for exams and xrays that were covered. For office #1, I paid $91 for an exam. I received the EOB from ins. stating they paid $90 to the office and patient responsibility is $1. I haven't heard anything from them.

*For office #2, I paid $164 for exam and xray. Insurance. covered it in full. Also, I had a tooth extracted from them that cost $325 and ins. paid $204. I get a bill from them saying I owe $325 when it should be $121. So wouldn't I get a refund or credit of $164 and have them apply it to the $121? What is going on?

* Office #2 keep telling me ins. company will reimburse me. The ins. company said they have already paid them. Haven't heard nothing from office #1. So wouldn't the offices give me a refund? I really need help on what to do. I hate paying the extra money when I could use it for books, food, etc. My primary dentist overcharged me but they sent a statement that I could be given a credit for a cleaning or given a refund check. Why aren't the other offices doing the same thing? Help and broke?!

6 years ago - 1 answers

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I believe you are confusing deductible with maximum benefit per year. Dental policies have a (relatively) small amount of benefits payable each year, but that does renew annually (usually Jan1. Once the insurance pays that amount out in the calandar year, it doesn't mean you can't go to the dentist. It just means that you have to pay for the additional services that are not covered. Usually, your dentist can work out a treatment plan to maximize your benefits by splitting up the care. Doing the most urgent in one year and the balance in the next year once the benefits have renewed. If you need alot of dental work, your dentist should be able to work out some kind of program for you.

If your dental coverage is an HMO or PPO, in order to maximize your benefit, you should see doctors within that network and follow whatever authorization policies they have for work other than x-rays and cleanings.

The scenario for office #1 appears to have been an in-network dentist, and the insurance (according to the EOB you got) paid them according to the contract that they have with him. You need to contact the dentist and tell them that the balance they are billing you for is a contractual writeoff and that they have essentially been double paid (since you also paid them). Request a refund and follow it up with a letter both to the dentist and a copy to the insurance company. Since this type of billing is probably against the agreement the dentist has, you may be able to get the insurance company to act in your behalf here too.

For office #2, follow the same procedure. What does the EOB say? Did you use an in-network doctor? If so, the doctor agrees to the amount that the insurance has set for that service which is usually discounted from the actual rate he charges.
EXAMPLE: The tooth extraction billed amount was $325. If this was a cnotracted dentist, the contract amount COULD have been $250 of which the insurance would pay your benefit amount of 80% or $200. You would be responsible for $50 and the dentist would write off the balance do to his agreement with the insurance company.

However, if the dentist in office #2 is not an in-network dentist, he could balance bill you for any work done there. You need to ask your insurance.

Finally, if I had a dentist that continued down this shoddy paperwork path, I would not see him again and I would make sure that his office was aware of it.

6 years ago