Are dentists ripping us off?

I’d say she’s absolutely incorrect. I can’t explain it any simpler than I already have. Your roofer analogy is just plain silly.

I haven’t read through all of this so excuse this if it has already been answered. Some of the responses hit close to the answer with side comments but miss the cause of the answer.

The practice is called balance billing.
The differences are:
If you go to an in network provider the provider is prohibited from balance billing back to the patient;
If you go to an out of network provider the provider is not limited and is able to balance bill the patient.

Balance billing example.
Take a mythical bill of $1,000.
In network insurance may “Allow” $500. The provider is contractually bound to accept that rate. The provider negotiates the acceptable rates with the insurance carrier.
Of that, the insurer may pay 80% = $400 (known as plan liability)
and the member would be responsible for the remainder up to the “Allowed” amount, $100 in this case (known as the member liability).

Out of network insurance may “Allow” $400. Note this is often less than the in network Allowed amount.
They may then pay 80% of that $400 = $320.
The insurer will see a member liability of $80.
Being out of network, the provider can balance bill the other $600 to the patient. The out of network provider is not bound to a contractual payment rate from the carrier. Which explains why they are out of network.

As someone already pointed out, many dentists may be more likely to stay out of network so that they can continue to balance bill the patient. Chiro’s too.

This isn’t a dental thing. This is true of all health insurance. It is designed that way to steer members to more cost effective care, or sometimes even more effective outcomes. Not all providers have the same rate of successful outcomes.

Make sure your dental provider is in network.

walleyevision wrote:

Dental insurance is not at all like medical insurance. It basically only covers routine visits. Dentists are smart. Once you accept insurance as a medical provider your profits dive.

There is this as well. Many dental plans have annual caps on claims. Once the patient passes that cap, all other procedures are paid out of pocket.

Still, if they are in network, they should still be bound to the contracted allowed amounts agreed to with the carrier. And they can’t balance bill the difference.

Deleted wrote:

How can profits dive by accepting insurance? You’re now getting steady run of clients with insurance.

I’m talking about good insurance, over $2,000 billed for an afternoon appointment.

The problem I’ve come to understand after talking with my dental insurance provider is this…..
– submitted charges are reduced to plan allowed amounts, for covered procedures. This discount is generally 35% less than the submitted charge. Dentists now this joining the plan and write off the difference.
-amalgam fillings are covered at 80%
-white fillings on posterior (back) teeth are only covered at 80% of the amalgam plan amount. He lies the problem…..because these are “alternately covered” procedures , the dentist can choose to write off the difference or not to. If they do, that’s great. Mine does not ….and therefore expects 100% of the submitted charge and isn’t apparently decent enough to knock down the amount, to the otherwise expected plan discount of 35% off all other submitted, covered procedure charges. So, full charge for the procedure. That’s not gonna work.

Just this loophole in the insurance that allows 100% of submitted charges on white, back fillings, increases my bill about $450, in addition to my existing portion and on top of what the insurance is paying too. It’s a $450 kick in the teeth!!

That doesn’t sound right. I would confirm that with your dental plan.

Note, I haven’t seen dental contracts. On the medical side, they are not able to balance bill non-covered claim lines if they are an in network provider. I assumed that same language would exist in the dental contract.

Step one. contact your carrier to verify if they are in network.
Step two, with the carrier, confirm the coverage and explain what the dentist is trying to do.

Step one. contact your carrier to verify if they are in network.
Step two, with the carrier, confirm the coverage and explain what the dentist is trying to do.

Done & Done
– there is no provision restricting a dentist from the (100% or bust) billing practice on “posterior composites”.

I pay the same 20% for the posterior as I do for an anterior composites but the difference is written off by contract with anterior composites.

It is up to the dentist to write off the difference (submitted vs allowed) on posterior composites. He must write off the same regarding anterior composites. My previous dentist in another state did write off regardless. The dentist I just fired billed out that difference, to get 100% of the $236 per tooth. The anterior composites are discounted roughly 35% by the plan. I’m sure that is healthily inflates also, to compensate for that plan discount.

I have absolutely verified (twice over the phone and once online) this week, with Delta Dental, that this dentist is still IN NETWORK. I have the highest coverage/ best plan that is available (PPO/Premier). I also verified with the dentist when we initiated our switch to him a year or more ago as well as before each appointment. That’s another lesson I learned years ago.

Dentistry looks to be a touchy subject.

Deleted wrote:

Step one. contact your carrier to verify if they are in network.
Step two, with the carrier, confirm the coverage and explain what the dentist is trying to do.

Done & Done
– there is no provision restricting a dentist from the (100% or bust) billing practice on “posterior composites”.

I pay the same 20% for the posterior as I do for an anterior composites but the difference is written off by contract with anterior composites.

It is up to the dentist to write off the difference (submitted vs allowed) on posterior composites. He must write off the same regarding anterior composites. My previous dentist in another state did write off regardless. The dentist I just fired billed out that difference, to get 100% of the $236 per tooth. The anterior composites are discounted roughly 35% by the plan. I’m sure that is healthily inflates also, to compensate for that plan discount.

That is very surprising. Sounds like sloppy contracting between Delta and the dentists.

Next I’d go to your HR benefits coordinator and let them know your feelings on this. At the end of the day, your employer (HR) decides what insurance you get to buy. Your employer offers these as benefits to working there. If they want these to be benefits then they should know how you feel about this “benefit” of being balance billed by an in network provider.

If enough employees are fed up with this practice HR should get bids for coverage from other carriers that do not allow the practice of balance billing.

Keep in mind, our economy is about as close as it ever gets to full employment. This means that it is becoming more difficult to retain workers or fill positions. If HR wants this to be a benefit for gaining or retaining employees, they should know your feelings while you hold a little more leverage.

Schiit, imagine if Allina or Fairview did this. You’d be out thousands from a normal delivery, possibly millions on premi twins.

Yeah, I’d be finding a new dentist too. I can’t say that I like my dentist so I wouldn’t recommend him either. haha. But at least he doesn’t pull this crap.

We need to talk…

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Well it’s official. My dentist (up to this week) is a crook.

I got a second opinion today and I have ZERO cavities! Ain’t that another kick in the teeth!

After being told I had no cavities today. I produced my pre-estimate from delta dental. Clearly showed specific teeth I supposedly needed cavities filled on my paperwork. Posterior composites, the ones I have been griping about here……the dentist today then double checked those specific teeth and I have absolutely no sign of a cavity in those exact teeth or any others.

I’m disgusted with this local dentist but I won’t trash him publicly. Maybe I should but I won’t do it here. I will definitely spread the word locally. My neighbors in this small town will all get the scoop.

So I have to edit this to add some funny (NoT) ….. I just stopped by my brothers house on the way home (different town, different dentist) and he says his 16 yr old son was told this week he has 7 cavities. How convenient. My nephew had 5 cavities this spring. What are the odds?

Deleted wrote:

Well it’s official. My dentist (up to this week) is a crook.
I got a second opinion today and I have ZERO cavities! Ain’t that another kick in the teeth!

That’s what I suspected. Glad you got a second opinion. This issue seems rampant these days. If you are regularly recommended dental work, you NEED to question it and get a second opinion.