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Old 02-11-2016, 03:32 PM   #21
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What bUU states regarding insurance payments being different for in-network vs out-of-network dentists sounds pretty standard in the dental insurance industry. Insurance tends to pay less to out-of-network dentists in part because there is no prior agreement on charges, leaving you, the subscriber responsible for the balance. The term "necessary and customary" leaves a lot of discretion to your insurance company to disallow or lower payments to out-of-network dentists--you just don't know! Stick to in-network dentists, or if none are convenient, I would research other dental insurance that have a better selection of in-network providers.
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Old 02-12-2016, 12:08 AM   #22
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What bUU states regarding insurance payments being different for in-network vs out-of-network dentists sounds pretty standard in the dental insurance industry. Insurance tends to pay less to out-of-network dentists in part because there is no prior agreement on charges, leaving you, the subscriber responsible for the balance. The term "necessary and customary" leaves a lot of discretion to your insurance company to disallow or lower payments to out-of-network dentists--you just don't know! Stick to in-network dentists, or if none are convenient, I would research other dental insurance that have a better selection of in-network providers.

I agree that in network would probably not have any extra.... but that is not what their brochure says... it says reasonable and customary at 100% in network or out of network.... their payment is far from the customary charges by dentist around here....

I did use a different insurer a couple of years ago and they paid 100% of my current dentists charges... again, I am paying a higher premium for them to reimburse out of network docs the same as in network...

I will be dropping this company and seeing if I can sign up for the one I had two years ago... if not, I will go without as I did last year....
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Old 02-12-2016, 04:59 AM   #23
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I agree that in network would probably not have any extra.... but that is not what their brochure says... it says reasonable and customary at 100% in network or out of network....
I've never seen such a thing. It would be a great service to us in retirement to have a dental plan that paid 100% in network or out... what insurance plan is it?
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Old 02-12-2016, 05:24 AM   #24
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trying to buy a single customer dental insurance policy that will pay out more than it takes in is unlikely to work out. In order to survive, insurance companies have to take in more than they pay out. Unless you have the clout of joining a large group of customers, so the insurance company has a chance of some of the premium payers actually NOT using the service (so they can collect more in premiums than they pay out in benefits), you are probably better off self insuring.

Also, remember, that when an employer provides access to dental insurance, the premiums are paid with pre-tax dollars, which again helps in making the product more cost-effective.
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Old 02-14-2016, 01:52 PM   #25
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We were offered 5 different dental plans as part of the retirement package from the former company. Talked to the billing person at our dentists office - she reviewed and said we are better off just paying ourselves as each plan had bad clauses ... And plans expensive. Eg. One had a waiting period of 6 months after diagnosis of infected tooth...with no retroactive coverage. right now we just need quarterly teeth cleaning and the odd xray...and get a 20% senior discount! We are lucky the former employer gives us about $4000 a year to pay premiums', medical, prescription and dental costs not covered by medicare and supplemental plans. Know some big dental expense could arise .. But no confidence that any of the offered plans would actually pay. Had such a goid plan when working - wish that was still offered!




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Old 02-14-2016, 06:30 PM   #26
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A subsidized dental plan from an employer can still be a good deal, so you shouldn't reject it out of hand.

We have one from DW's former employer. Our wonderful dentist has had his hands full with us due to an accident DW suffered, and his total billing for the two year period 2014-15 was close to $5,000.

Of that $5,000, the insurance paid just under $1,600 and we paid the rest. But our premiums were only $720, or roughly half what they paid.
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Old 02-15-2016, 04:29 PM   #27
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A subsidized dental plan from an employer can still be a good deal, so you shouldn't reject it out of hand.

I agree; I'm betting that premiums are lower for employer plans because the covered employees will include a large number who rarely go to the dentist unless they have a problem, so they're cheaper to insure. Those of us who buy private plans are more likely to go for the cleanings and probably anticipate an occasional major repair based on past experience.
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Old 02-15-2016, 05:30 PM   #28
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It sounds like you have 2 insurances: your regular health insurance, and your dental plan. Did the dentist bill your primary insurer, or your dental insurer?

Our primary insurance is Federal BC/BS, which has a tiny dental benefit for preventive care. In addition, we carry Humana Federal Dental insurance, which pays about 40% of "reasonable/customary" charges for restorations. The dental practice charges us a co-pay they agreed on with Humana. We pay the Humana co-pay up front at time of service. For preventive care, we pay nothing up front.

But there is always, always a hassle that makes it look like we are being charged much more than agreed on. By law, the dental office must bill the "primary" insurer first. Then BCBS sends an EOB denying the claim. Then the dental office must submit the BCBS EOB to Humana along with their claim.

Unfortunately, the dental office never seems to be able to get past the BCBS refusal. Then their computer sends me a threatening letter for non-payment. Then I have to send MY copy of the BCBS EOB to the dental billing office, requesting that they send it to Humana along with their claim. For complicated bills, like Mr. A's implant, it can take months to get this straightened out, and meanwhile, I get a threatening letter every month.

Just wondering if this has any bearing on your situation.

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Old 02-15-2016, 05:38 PM   #29
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I still say it's too soon to know if the coverage was worth anything. An EOB is *not* a bill. States it right on the EOB. What will be interesting is the bill from the dentists office.

Since the dentist is out of network, they balance bill the entire amount, or a part of the amount.
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Old 02-15-2016, 05:56 PM   #30
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It sounds like you have 2 insurances: your regular health insurance, and your dental plan. Did the dentist bill your primary insurer, or your dental insurer?

Our primary insurance is Federal BC/BS, which has a tiny dental benefit for preventive care. In addition, we carry Humana Federal Dental insurance, which pays about 40% of "reasonable/customary" charges for restorations. The dental practice charges us a co-pay they agreed on with Humana. We pay the Humana co-pay up front at time of service. For preventive care, we pay nothing up front.

But there is always, always a hassle that makes it look like we are being charged much more than agreed on. By law, the dental office must bill the "primary" insurer first. Then BCBS sends an EOB denying the claim. Then the dental office must submit the BCBS EOB to Humana along with their claim.

Unfortunately, the dental office never seems to be able to get past the BCBS refusal. Then their computer sends me a threatening letter for non-payment. Then I have to send MY copy of the BCBS EOB to the dental billing office, requesting that they send it to Humana along with their claim. For complicated bills, like Mr. A's implant, it can take months to get this straightened out, and meanwhile, I get a threatening letter every month.

Just wondering if this has any bearing on your situation.

Amethyst
Wow. in 38 years of practicing dentistry I don't think I've ever run across a medical insurance provider who covered anything for any dental procedure. Are you saying that the BC/BS Medical plan is the primary insurer for non-preventive procedures that they won't cover?
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Old 02-15-2016, 09:03 PM   #31
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I still say it's too soon to know if the coverage was worth anything. An EOB is *not* a bill. States it right on the EOB. What will be interesting is the bill from the dentists office.

Since the dentist is out of network, they balance bill the entire amount, or a part of the amount.

They balanced billed everything except for fluoride..... I will be dropping this insurance and checking what I had two years ago... it paid 100% of the cleanings....
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Old 02-15-2016, 09:05 PM   #32
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It sounds like you have 2 insurances: your regular health insurance, and your dental plan. Did the dentist bill your primary insurer, or your dental insurer?

Our primary insurance is Federal BC/BS, which has a tiny dental benefit for preventive care. In addition, we carry Humana Federal Dental insurance, which pays about 40% of "reasonable/customary" charges for restorations. The dental practice charges us a co-pay they agreed on with Humana. We pay the Humana co-pay up front at time of service. For preventive care, we pay nothing up front.

But there is always, always a hassle that makes it look like we are being charged much more than agreed on. By law, the dental office must bill the "primary" insurer first. Then BCBS sends an EOB denying the claim. Then the dental office must submit the BCBS EOB to Humana along with their claim.

Unfortunately, the dental office never seems to be able to get past the BCBS refusal. Then their computer sends me a threatening letter for non-payment. Then I have to send MY copy of the BCBS EOB to the dental billing office, requesting that they send it to Humana along with their claim. For complicated bills, like Mr. A's implant, it can take months to get this straightened out, and meanwhile, I get a threatening letter every month.

Just wondering if this has any bearing on your situation.

Amethyst

I do not know why you have to go through that....

Our medical insurance only covers dental if there was an accident.... IOW, something knocked out a tooth... normal cleanings, fillings, crowns etc. would not be covered....
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Old 02-16-2016, 03:16 AM   #33
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Wow. in 38 years of practicing dentistry I don't think I've ever run across a medical insurance provider who covered anything for any dental procedure. Are you saying that the BC/BS Medical plan is the primary insurer for non-preventive procedures that they won't cover?
I'm describing the tortured claims process which the billing office claims they must, by law, pursue. BCBS pays a small preventive care benefit, and I think there may be something for emergencies that are deemed more medical than dental. No restorations are covered.
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Old 02-16-2016, 04:57 AM   #34
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I'm describing the tortured claims process which the billing office claims they must, by law, pursue. BCBS pays a small preventive care benefit, and I think there may be something for emergencies that are deemed more medical than dental. No restorations are covered.
my question is whether the BCBS is considered the "primary" dental insurance. IF they are, then the claim has to go through them first, even if they don't pay. If that's the case, then the provider has to jump through that hoop first, wait weeks for the denial, and then file to the secondary who actually will pay something, but not for another "few weeks".
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Old 02-16-2016, 05:15 AM   #35
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Amethyst, I think I know what's going on in your case. If your office accepts a lot of insurance PPOs, then they have a fee schedule that moves all over the place depending upon which contracts they've signed up for. They probably have another one for the folks who don't have any insurance. The INSCO will pay their agreed upon fee, or the charged fee, whichever is lower, so the provider, in order to make sure they get the maximum fee, will submit a fee higher than any of the agreed upon fees and let the insurance company knock it down. Since you are getting a dunning letter before your secondary provider has knocked it down, you are seeing the big number. It's a goofy game. One, as a dentist, I never played.
But, because I never played along with the INSCOS, they were constantly trying to make my life miserable by sending playing with my claims, "losing" submissions, denying claims that once we contested they would pay, but in the meantime my staff was wasting time and my cash flow was compromised.
The main thing that dental insurance "insures" is often the INSCOS cash flow. Everything else is secondary to that.
Frankly, having to deal with them is the biggest reason why I'm OUT of the profession in 2 weeks. I wouldn't mind just dealing with patients and fixing teeth, but the INSCOS have left me with no more hair to pull out.
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Old 02-16-2016, 08:04 AM   #36
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Frankly, having to deal with them is the biggest reason why I'm OUT of the profession in 2 weeks. I wouldn't mind just dealing with patients and fixing teeth, but the INSCOS have left me with no more hair to pull out.
Wow- I knew doctors had these headaches but not dentists. We got Delta Dental for DH because our dentist recommended them and they've been fine. For people who have enough dental issues to want insurance, it might be good to ask your dentist which companies are best to work with.
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Old 02-17-2016, 06:23 AM   #37
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If your office accepts a lot of insurance PPOs, then they have a fee schedule that moves all over the place depending upon which contracts they've signed up for. They probably have another one for the folks who don't have any insurance. The INSCO will pay their agreed upon fee, or the charged fee, whichever is lower, so the provider, in order to make sure they get the maximum fee, will submit a fee higher than any of the agreed upon fees and let the insurance company knock it down.
Yes, that is an accurate description of what is going on. It took me many, many hours of bird-dogging with a certain type of pig-headed administrator, at the practice and at both insurance companies (They must all hire from the same pool) to figure it out. Each insurance company's administrators blamed the other one, and they both blamed the dental office. The dental office admins employed the phrase "It's your respon-si-bil-i-tee." Meanwhile, all I had were receipts for co-pays, and dunning letters threatening my credit rating.

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But, because I never played along with the INSCOS, they were constantly trying to make my life miserable by sending playing with my claims, "losing" submissions, denying claims that once we contested they would pay, but in the meantime my staff was wasting time and my cash flow was compromised.
Over the past 10 years, our family has had a great many dental procedures. About $30,000 in co-pays alone, and I am pretty sure we ended up overpaying in the earliest years after the office stopped billing Humana directly, and went to the two-billing procedure.

It has long been apparent that our dental practice is pushing some of the staff's headaches onto the patients. They know that some of us cannot live with "threatening letters," although others probably ignore them. So now, when I get a letter, I dutifully pull out my own BCBS EOB, scan and email it to their billing office. And I check Humana's web site frequently to ensure the various claims are being turned in.

For those who are thinking, "Why didn't you change practices?" Well, I thought of it. I work out at the same gym as a dentist whose practice accepts Humana, and she told me the insurance is handled the same way at her practice!

.[/QUOTE]
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Old 02-17-2016, 06:29 AM   #38
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12 more days and I'm out...actually, I don't deal with the INSCOS anymore, I've sold the practice so I just work there. And that's 12 calendar days. Only 4 work days, and 3 of those are half-days. Happy Dance!
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Old 02-18-2016, 10:46 AM   #39
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Good for you doc, you sound like a dentist I would've been glad to have visited. Thanks for the insights on how your practice worked and the confirmation on how the dental insurance market is so crappy for unemployed folks.
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Old 02-19-2016, 07:02 AM   #40
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Humana Federal's benefits are a little better than Delta's, last time I checked. For us, at any rate.

Swapping secondary insurers would not make any difference for us. The dentists at the practice don't deal with the insurers. The problems are clerical/administrative in nature. The admin and billing people in the practice are overwhelmed and testy, and the turnover is high.

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Wow- I knew doctors had these headaches but not dentists. We got Delta Dental for DH because our dentist recommended them and they've been fine. For people who have enough dental issues to want insurance, it might be good to ask your dentist which companies are best to work with.
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