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Whats the difference between a doctor and a dentist?

A doctor doesn't call him(her)self a dentist.

JorgeBurrito said: I have dental insurance that does not have a network. I can go anywhere, but the insurance company only covers a certain amount for a given procedure and anything else beyond that is my responsibility. I say this just in case anyone is reading this and has a similar setup and after reading some of the above posts think they are getting ripped off. An insurance setup where you have in network dentist is very different and I agree OP sounds like he is getting ripped off.

I have one of those also. I have "dual" dental insurance.
For a procedure that both carries cover at 60% of "reasonable and typical" - I'm still about 20-30% out of pocket.

Doing a little research online, the 3rd party company that sets "reasonable and typical" rates is owned by a major health insurance company... Their set rates are neither reasonable nor typical. I wish they'd just let me negotiate for cash and then pickup the rest of the "reasonable and typical" rates.

I've been to in-network dentists... I've made that mistake 3 times. It's just not worth it to have assembly-line dentistry.

For clarification, the crown procedure is 50% covered (not 100% as some ID mentioned), that's why my wife paid $500 up front (50% of $1000 the dentist asked for). Secondly, she is in-network provider as she complied with all other misc claims (didn't do balance billing on those).

From what I read, I am going to ask the dentist put her request (for the difference) on paper and forward it to the insurance company. Thank you everyone for your comments, now I am feeling better and going to stick to my guns on this matter. Probably, I'll find a new dentist in my area meanwhile.

MiaFLSurf said: Whats the difference between a doctor and a dentist?

A doctor doesn't call him(her)self a dentist.


Most people assume doctor means you went to med-school. Same thing applies to chiros, pharmacist, optometrist, etc. That is the way the media has molded out thinking.

mafoi said: For clarification, the crown procedure is 50% covered (not 100% as some ID mentioned), that's why my wife paid $500 up front (50% of $1000 the dentist asked for). Secondly, she is in-network provider as she complied with all other misc claims (didn't do balance billing on those).
Did the doctor become "out-of-network" in 2010 by any chance, when this last procedure was presumably done?
What does the EOB from insurance state?

The dentist is still in-network. Some procedures performed after the crown had no billing issue among the dentist, me, and CIGNA.

Why dont you simply ask the dentist why he/she is charging the full fee when he/she is in-network?
His/her excuse might be a different type of crown (not covered or downgraded to a porcelain fused to crown) but still a negotiated fee.

So if she placed a ceramic crown which had been downgraded, ask him/her whey it wasn't explained to your wife and the fee should still derive from CIGNA's fee schedule, not his.

mafoi said: For clarification, the crown procedure is 50% covered (not 100% as some ID mentioned), that's why my wife paid $500 up front (50% of $1000 the dentist asked for). Secondly, she is in-network provider as she complied with all other misc claims (didn't do balance billing on those).Exactly how much did the CIGNA pay to the dentist? If you paid $500 up-front, then it appears that CIGNA owes you $84 (you each pay $416), providing you had met your deductible.

If it's me I'd go directly to the dentist's office and speak to the head claims person and see the exact area of dispute. There might be some fine print in the contract.

eta: Since you already paid $thousands last year, presumably to this dentist, definitely find a new one.

^^^--- Is correct.

Just politely ask the dentist for a bill.. Send to Cigna.
Send EOB to dentist.

This is called "Balanced Billing". If you google it, you will find that many states have laws against this practice. When a provider signs a contract with an insurance company, part of that contract includes a clause to not bill the patient above and beyond the agreed upon rate for services performed.

Again, this is in 99% of cases and circumstances not allowed, either by law or by contract. I would NOT pay the bill and kindly inform the provider what they are doing is likely illegal.

here's an article, couple years old, still accurate: link

$1000 dentist charge
$832 CIGNA contracted amount
$25 my deductibles
CIGNA paid (832-25)*50%=403.50

The dentist asked me for $1000-403.50=596.50. We already paid $500, and we should pay 403.50 plus 25 deductible.

curtisekarr said: mafoi said: For clarification, the crown procedure is 50% covered (not 100% as some ID mentioned), that's why my wife paid $500 up front (50% of $1000 the dentist asked for). Secondly, she is in-network provider as she complied with all other misc claims (didn't do balance billing on those).Exactly how much did the CIGNA pay to the dentist? If you paid $500 up-front, then it appears that CIGNA owes you $84 (you each pay $416), providing you had met your deductible.

If it's me I'd go directly to the dentist's office and speak to the head claims person and see the exact area of dispute. There might be some fine print in the contract.

eta: Since you already paid $thousands last year, presumably to this dentist, definitely find a new one.

Pun said: Why dont you simply ask the dentist why he/she is charging the full fee when he/she is in-network?
His/her excuse might be a different type of crown (not covered or downgraded to a porcelain fused to crown) but still a negotiated fee.

So if she placed a ceramic crown which had been downgraded, ask him/her whey it wasn't explained to your wife and the fee should still derive from CIGNA's fee schedule, not his.

+1
Since it was specifically for a crown where the so called bal. billing is done, I suspect your insurance benefits would pay for crowns only for a certain category and you were offered one for a higher category. If that were true, your EOB is likely to say so.
ETA: For a procedure involving several thousands, didnt you guys do a insurance pre-auth? Even if this was not required specifically, it lets you know upfront what exactly you will be liable for and minimize disputes about billing (both with dentist and ins.) later. You dont also have to "over-pay" the dentist and look for a refund later since dentists often bill at higher than the insurance negotiated rate.

Yes, the dentist did pre-authorization or estimates with CIGNA before the surgery. There is nothing in EOB regarding different grade of crown. Thank you for your comments.

uutxs said: Pun said: Why dont you simply ask the dentist why he/she is charging the full fee when he/she is in-network?
His/her excuse might be a different type of crown (not covered or downgraded to a porcelain fused to crown) but still a negotiated fee.

So if she placed a ceramic crown which had been downgraded, ask him/her whey it wasn't explained to your wife and the fee should still derive from CIGNA's fee schedule, not his.

+1
Since it was specifically for a crown where the so called bal. billing is done, I suspect your insurance benefits would pay for crowns only for a certain category and you were offered one for a higher category. If that were true, your EOB is likely to say so.
ETA: For a procedure involving several thousands, didnt you guys do a insurance pre-auth? Even if this was not required specifically, it lets you know upfront what exactly you will be liable for and minimize disputes about billing (both with dentist and ins.) later. You dont also have to "over-pay" the dentist and look for a refund later since dentists often bill at higher than the insurance negotiated rate.

EOB doesn't show different grade of crown (sometimes it doesn when downgraded). Just ask the dentist, if diff type of crown was placed ask him why it wasn't discussed before the tx, and that it should still fall under the CIGNA fee schedule.

This could and should have been fixed by ins regulatory laws. But why should politicians work in the interest of ordinary citizens when it is the ins cos and doctor groups who finance their campaigns?

mafoi said: $1000 dentist charge
$832 CIGNA contracted amount
$25 my deductibles
CIGNA paid (832-25)*50%=403.50

The dentist asked me for $1000-403.50=596.50. We already paid $500, and we should pay 403.50 plus 25 deductible.

You owed to dentist: $403.50 + $25
You paid: $500
They owe you: $71.50

Unless what Pun and others have said about a different crown is true, at which point I would take Pun's latest advice.

I suggest you pay the bill then have Cigna make a complaint against them. I've seen this happen before. Then the dentist will be forced to refund your money. After you pay the bill, send a copy of the relevant materials to Cigna (call them first to find out where to fax it). Send a copy of the check, a copy of your insurance card, a copy of the invoice, etc. The dentist will be at risk of losing their contract with Cigna if they do not refund your money. The dentist will not want to lose that many patients over a measly $168.00. What the dentist is doing is probably attributable to ignorance and the folks at Cigna will need to be the ones to show them the light since they are the ones with some influence.

Also send a polite letter to the dentist saying I am disappointed that you agreed to do this procedure with the knowledge that I was referred to you by an insurance provider with whose practices you are very familiar and you have now turned to me to provide you with additional funds beyond what you and the insurance provider have agreed to. This is ethically wrong and as I am sure you know, several states have already banned this practice with legislation. I hope you realize the error of your ways so that I do not have to take the next steps of writing a letter to the [local newspaper, local tv station] to ask them to highlight your unethical practices. Be advised that I will take all legal and ethical actions against your practice if you persist in this shortminded folly.

Or you can write:

Dear Dr. Smith,

Some deranged person appears to have stolen stationary from your office and is using it to make outrageous demands. I have enclosed a copy of the document in an effort to help you find the person who is dragging your good name into ill repute.

^^^^green for upper half; red for lower.

curtisekarr said: ^^^^green for upper half; red for lower.

would have thought it would be the other way around.

JorgeBurrito said: I have dental insurance that does not have a network. I can go anywhere, but the insurance company only covers a certain amount for a given procedure and anything else beyond that is my responsibility. I say this just in case anyone is reading this and has a similar setup and after reading some of the above posts think they are getting ripped off. An insurance setup where you have in network dentist is very different and I agree OP sounds like he is getting ripped off.Mine is the same. What the insurance company calls the typical or customary charge for a service is not always the case either. I had to pay once because it was above what the insurance considered customary so called a few random offices in town out of the phone book and asked how much they charged for the service (just a routine cleaning) and all were very close to what my dentist charged and above what the insurance company deemed customary.

luvdeals said: JorgeBurrito said: What the insurance company calls the typical or customary charge for a service is not always the case either. I had to pay once because it was above what the insurance considered customary so called a few random offices in town out of the phone book and asked how much they charged for the service (just a routine cleaning) and all were very close to what my dentist charged and above what the insurance company deemed customary.

It's not the routine cleanings that will get you - it's the procedures like a crown.. When your insurance carrier says reasonable and customary is mid $600s...

UCR = usual, customary, and reasonable

Each ins company have a formula on how they arrive at their UCR. At one time BCBS used the 90%ile figure. For each zip code they would sort all the providers' fees and then designate the 90%ile as their UCR. Some cheaper ins cos used to use a lower figure.

You are entitled to know how they arrive at the UCR and if they do not tell you, contact your state's Ins Commissioner.

Are you sure that your dentist is in network? It sounds like they are not.

katx said:
Each ins company have a formula on how they arrive at their UCR. At one time BCBS used the 90%ile figure. For each zip code they would sort all the providers' fees and then designate the 90%ile as their UCR. Some cheaper ins cos used to use a lower figure.


The company setting my UCR is owned by United Healthcare.
Here, you can read about how they set rates.. Explain to me how I'm covered for a procedure at 120% (dual insurance) - my dentist isn't charging anything unusual - and I'm still paying out of pocket.

Oh, wait.. I can explain that:

See who sets my UCR rates

Sad thing is, this company doesn't change the rates until months down the road.

mungbai said: Also send a polite letter to the dentist saying I am disappointed that you agreed to do this procedure with the knowledge that I was referred to you by an insurance provider with whose practices you are very familiar and you have now turned to me to provide you with additional funds beyond what you and the insurance provider have agreed to. This is ethically wrong and as I am sure you know, several states have already banned this practice with legislation. I hope you realize the error of your ways so that I do not have to take the next steps of writing a letter to the [local newspaper, local tv station] to ask them to highlight your unethical practices. Be advised that I will take all legal and ethical actions against your practice if you persist in this shortminded folly.

Or you can write:

Dear Dr. Smith,

Some deranged person appears to have stolen stationary from your office and is using it to make outrageous demands. I have enclosed a copy of the document in an effort to help you find the person who is dragging your good name into ill repute.


Well if you do send such a letter then don't plan on going back to that dentist. Because, next time, you might magically need a few painful root canals. But seriously, be careful not to send anything that could be construed as threatening to a medical professional. You could hear from their attorney.

EVERY state has a medical review board and will investigate complains. I had a "drug dealer" doctor that we refered to the agency. They were ticked off! but the fact is that a review goes in their record and their reputation matters more to them than an irate letter from the patient. Since you have documentation, I sugest you send it to the review board and demand that the dentist repay you the $20.00.

It does not look good for them and frankly, I'd be shopping for a different provider in the future. I am a spousal caregiver, and I can tell you that my knowledge of the medical community far surpasses what I thought I needed to know. They are "SERVICE PROVIDERS" and you can and should interview people to make sure you are all on the same page. It has gotten to the point that I interview these people regarding charges and procedures before we "hire" them.

I don't know what state you live in, otherwise I'd be sending you the right address and phone numbers to call, the best thing I can offer is to call your department of health and ask for a consumer protection number statating clearly that you want to submit a complaint against a doctor and that you want the billing issue resolved. BILLING is the key word, there is a department that exclusively handles billing (over billing) by doctors.

Good luck and PEACE

It probably has nothing to do with the dentist, it's probably a screw up in their accounting department, or person. I work in a lot of doctors offices and screw ups are rampant with insurance and payments. It's really very difficult on their end to get things just right, and they are always cutting refund checks to people due to mistakes.

Here are a couple of web sites where you might find help


The Patient's Advocate


Alliance of Claims Assistance Associates

Couple of things:

The OP stated that the dentist is in the CIGNA provider network. It sounds like a standard PPO Dental plan and CIGNA is a good company. So any discussion of U&C reductions is misplaced-U&C is only used on out of network claims.

Generally, if you contact CIGNA customer service and explain the issue, their provider relations dept will reach out to the provider and re-explain the terms of the contract. the provider is specifically not allowed to balance bill in any PPO type contract.

Second option-and I'm assuming this is a plan purchased or provided through you or your wife's employer. Go to your HR Dept. and explain the problem. Your HR Dept. will have acccess to: A) CIGNA account service representatives and B) the Employee Benefits Broker (Agent) who sold the Company the plan. They can usually get quick action and you may also be able to receive an email stating specifically that the provider owes you some money.

Employee Benefits Brokers/Agents deal with this all day every day. They usually have specific staff who raise hell at the ins. carriers for the actions of a Dr./Dentist that is part of a provider network.

Dr. Dentist offices can be terrible about things like this. They have no way to determine usually if the ins. co. is paying them correctly, because their systems are not set-up to even recognize discounts. If you see a Dr. bill that says "write off", that is usually the network discount that has been applied to their change by the Ins. Co.

mafoi said: Maybe a little bit confused after reading the title. Here is a short version but better than the title:

Our dentist asked us to pay the difference between what she asked the insurance company and what the insurance paid her.

Still confusing? Longer version. My wife had a crown done last year. The dentist asked $1000 for the service (claim sent to CIGNA). However, she is in-network service, the negotiated price between the dentist and CIGNA is $832. So, after she received 1 check from CIGNA, she asked us to pay the difference $168. So, I called CIGNA, and was told by CIGNA customer service that I don't need to pay that $168. Now, the dentist threatened to forward this bill to collect agent. She said this will affect my credit score. We paid thousands last year for my wife's teeth already, and we don't really care that much about this $168. But our feeling is really hurt and it's like been bullied. BTW, we don't have any other big purchase coming up, so we don't have immediate concern on the credit score. What I am concerned is the annoying phone call (she has only my Google Voice number, so I can block unknown callers? right? sweet).

Even longer version. My wife paid in advance some money, so according to CIGNA, the dentist owe us $20. Feeling insulted, I sent her a letter ask for a refund within 30 days. What should I do next? Small claim court? Forward my request of $20 to collect agent? I am really pissed off. It's not medical care, it's rip off, even with the insurance.





Anti-Dentite mofo SEINFELD




Kramer: Jerry's an Anti-Dentite
This Seinfeld sound bite has been removed due to a DMCA request from the copyright owners of Seinfeld.


JERRY: So you won't believe what happened with Whatley today. It got back to hime that I made this little dentist joke and he got all offended. Those people can be so touchy.
KRAMER: Those people, listen to yourself.
JERRY: What?
KRAMER: You think that dentists are so different from me and you? They came to this country just like everybody else, in search of a dream.
JERRY: Kramer, he's just a dentist.
KRAMER: Yeah, and you're an anti-dentite.

JERRY: I am not an anti-dentite!
KRAMER: You're a rabid anti-dentite! Oh, it starts with a few jokes and some slurs. "Hey, denty!" Next thing you know you're saying they should have their own schools.
JERRY: They do have their own schools!
KRAMER: Yeah!....

katx said: This could and should have been fixed by ins regulatory laws. But why should politicians work in the interest of ordinary citizens when it is the ins cos and doctor groups who finance their campaigns?
I agree with you that medical billing needs a major overhaul. However, my version wouldn't stop at eliminating balance billing but would eliminate any discounting. All medical providers must have a "list price" and charge that to everyone (cash or insurance patients). Medical billing is beyond shady and I think it is ridiculous that I have to use my insurance card like my Kroger plus card in order to obtain a fair price. Imagine if your auto repair shop gave discounts of 20-60% off of their "list price" based upon the car insurance you have. No insurance--that $19.99 oil change could run $100.

People are way off base in this thread about the issue of balance billing. Some states have made this pratice illegal, but it is not illegal everywhere. Perhaps if OP posts his state we could give more specific advice. Just because your doctor is not abiding by their contracted rate does not mean your state regulatory board or local prosecutor will investigate them or that they broke any official legal codes or regulations. Medical boards only care about doctor malpractice, abuse, or improper prescription writing. State insurance commissioners care about insurance fraud (i.e. doctors and patients submitting fake claims).
My wife had a balance billing attempt by a dentist, but the state insurance commissioner (GA) specifically stated on their website that they do not accept balance billing complaints. Fortunatley for us the dentist billed her insurance for a cleaning and x-rays on a return trip for a filling when he actually did not do a cleaning or take x-rays, so we reported him for insurance fraud (after several phone calls and letters didn't resolve the billing problems). After my wife wrote a letter telling them she had contacted the insurance commissioner about the insurance fraud things were immediately resolved. In the end it turned out (supposedly) to be a sloppy office manager that they ultimately fired. My wife never went back to this dentist and told all of her coworkers who used him to stop going there.

OP would you please edit your subject to read >>Dentist instead of doctor. It's extremely misleading.

TYTBUDGET

I agree. No PhD would ever do that.

+1 for varies by state. I think I posted something about this a while ago for ER bills. In NJ, there is a maximum amount a hospital can charge for services that varies down to the day service is performed. The insurance companies have a record of this ...

I also took the route of getting both the insurance company and the billing department of the hostpital on the line together and they took care of the remaining balance ...

Vmlinux said: It probably has nothing to do with the dentist, it's probably a screw up in their accounting department, or person. I work in a lot of doctors offices and screw ups are rampant with insurance and payments. It's really very difficult on their end to get things just right, and they are always cutting refund checks to people due to mistakes.

Nope, its a dentist type of thing. Have had so-called "balance billing" happen from several dentists and NEVER a "real doctor" (aka MD.) Quest Labs got into trouble years ago for this years ago and has since quit this practice, but everyone should look at their bills regardless.

If it truly is due to ineptitude of the dentists accounting departments, that is the dentist's problem as they are the ones who hire the incompetents. Firing them and replacing them with competent personnel seems like a better alternative.

This is a major cause of financial arguments in my household. My wife just pays any medical bill that comes our way. I have had to unwind balance billings like 10 times. Luckilly I have always gotten my money back, but its annoying. To the person that said good luck getting you money back if you overpay, I have never not gotten my money back. Sometimes it takes multiple phone calls and faxes of EOBs but the Drs, Dentists, Hospitals have always come through. I have even gotten money back from out-of network physicians that claimed to be in network only to find out later they were not. (this was easier than expected) and from out of network labs used by in-network physicians (much harder than expected)

I think OPs dentist probably really thinks they should get the extra $. My dentist is terrible with her billing. She never understands the rules and they change every year.

Mickie3 said: Quest Labs got into trouble years ago for this years ago and has since quit this practice, but everyone should look at their bills regardless.


+1 on Quest labs, they were the worst. I havn't noticed any bills from them recently but I Just throw away any mail from them.

A few pointers:
I-Dont forget the maximum calender year benefits that your dental insurance plan pays out. (this max benefits includes usual 2 checkups, cleanings, and bitewing x-rays, as well as other procedures). Anything over the maximu, you pay.
II-Crowns are all priced based on the codes used: D2750 crown porcelain-fused high noble metal and D6066 implant supported porcelain-metal crown are high priced. Other codes, D2790 high noble full cast, D6210 pontic high noble metal, D6240 pontic porcelain to high noble, D6780 abutment high noble 3/4 cast are similarly priced, D2720 crown-resin with high noble, D2740 porcelain/ceramic substrate, D2782 crown 3/4 porcelain/ceramic. Were there any other procedures included, such as D2950 core build-up including pins, D2952 cast post and core? These are averaged at $290. 3320 bicupsid endodontic therapy.
III-Usually, among the new patient forms they state that insurance companies do not set their fees, but they do establish a list of fees that they refer to as "usual and customary." The insurance companies my reimburse you a percentage of this "usual and customary" fee. But, regardless of how much your insurance covers, their fee is your responsibility.
IV-Do people leave out their DOB and SSN of all the new patient forms at a dentist and/or doctor? Most office staff wont process your papers or allow services without it. Also, doesnt the names and addresses of patient have to match with the records with the insurance company.
V-File a complaint to your insurance company, your state's consumer affairs or protections office, and/or Department of health for billing issues.



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