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Dental Bill Question regarding "medically unnecessary" claim denied

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3 years ago I was at my dentist and he told me I needed a crown done. There wasn't enough tooth left to replace an old filling etc. I've had this sort of work done before as I get older so i said go ahead.

Some time later I find out the insurance didn't pay for it and the claims analyst sent back detailed notes and X-rays etc. saying that the work should not have been performed because the crown was too close to the root (I think - I'm going from memory). My next trip to the dentist I'm like, WTF? He said they would appeal it, give more detail, insurance was full of it etc "don't worry, they just don't want to pay". So spouse and I call insurance they explain that the work should not have been done and tell me I AM NOT OBLIGATED TO PAY because it was unnecessary work.

Whenever I bring this up, the dentists office quietly drops the subject.



Well today (3 years later) I am in for a cleaning and they bring it up again, the girl is trying to show me why and how much I owe etc. I'm like wait just a minute, I always ask if I have a balance, I am always told no.

If the guy should get paid and the insurance screwed me I want to pay him (It's like $600 ) but, if I'm not obligated because of this I'd like to know. I would still probably pay him something and negotiate it down if thats the case, he had expenses etc. he seems to be pretty fair to me (my wife no longer goes there, she hates him for various reason but whatever)

When they started going over the last 5 years of my bills today some things didn't add up, and suddenly they shut up, she started to tell me that I couldn't leave without setting up a "payment plan" I was pi**ed, and so I started being like, well wait, this doesn't add up, and neither does this and.... and then I said I would talk to my attorney about it (which I probably will because I'm just mad).  She ended the conversation saying , well just look it over and if you have questions call me (She couldn't explain how they got to the balance they did- she was now flustered)

I was so mad I left without my phone and when I walked back in to get in she was talking to the dentist about it and I could see he was shocked that I had walked back in and desperate to shut her up, and that made me even madder after I left. Either she was bitching about me or didn't understand the bill or something.

I've always paid my and my spouses bill and I get three cleaning a year cuz of gum disease. He's made a pretty penny off our family our insurance and I am just PO'd about the way I was treated. 

Does anyone know, if the insurance said it was medically unnecessary am I exempt from paying??

Thanks all in advance...

EDITED TO ADD: In the end everything worked out, because he is in network he is not allowed to bill me. The insurance company is contacting him and telling him to let it go. Thanks Again to everyone who chimed in, take good care of your teeth, they can be expensive.....

Member Summary
Most Recent Posts
Because imho, this may be a situation where the insurance is finding a technicality to avoid paying and the dentist prob... (more)

bucksandreds2185 (Apr. 20, 2017 @ 1:38p) |

A dentist office have plenty of time to get pre-approval.  My dentist had to take pictures, do write-up, get rejected, g... (more)

ZenNUTS (Apr. 20, 2017 @ 2:08p) |

Because it's a huge conflict of interest on both sides.

One side would argue to the end of time that every single procedu... (more)

justignoredem (Apr. 20, 2017 @ 3:29p) |

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Why would you go back to a dentist who (according to your insurance) is performing unnecessary procedures on you?

It is time to find a new dentist.

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If the dentist is in network a determination that it wasn't necessary normally means they don't get paid.

Overall, I rather suspect you're looking at a case of a sloppy accounting department. I've hassled with such stuff before--there's a bill in the system that is invalid for some reason. Sometime down the road they recheck their data and the old bill gets resurrected. Strange how they are so much better at figuring out they're owed money than figuring out they aren't owed money.

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JepJepJep said:   Why would you go back to a dentist who (according to your insurance) is performing unnecessary procedures on you?

It is time to find a new dentist.

  
I wouldn't be too harsh here.  It doesn't sound like he did something unnecessary, but rather in a case that was near the edge he chose the more expensive option and the insurance disagrees with that choice.

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jesrf said:   ...

Does anyone know, if the insurance said it was medically unnecessary am I exempt from paying??

Thanks all in advance...

  

Thats what your insurance company said.   Right?

If youre not required to pay for unnecessary procedures then thats got to be part of the contract between the insurer and the dentist.      The dentist probably agrees that they won't bill covered patients for unnecessary procedures because the insurer doesn't want to have to pay for unnecessary procedures.    
If so then I wish all insurance worked like that...

 

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LorenPechtel said:   If the dentist is in network a determination that it wasn't necessary normally means they don't get paid.
 

  +1. It dentist is not "in network", it is a different story.
Some dentists are notorious for doing unneeded work (to pay for the fancy office equipment and their yacht). I had one who always found 2-3 cavities that needed to be worked on. Ignored him and eventually changed dentist. Have not had anyone say I had a cavity (it has been over 10 years since I dropped the "bad" dentist).

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Thanks for the responses. To clarify, the insurance felt that more work was necessary not less. In fairness it's been 3 years and it seems fine. I do agree, probably time to find a new dentist, but I've been busy. And I only go ages times a year

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jesrf said:   Thanks for the responses. To clarify, the insurance felt that more work was necessary not less. In fairness it's been 3 years and it seems fine. I do agree, probably time to find a new dentist, but I've been busy. And I only go ages times a year
  This is so confusing.  First you said that the insurance co said that the work should not have been performed and now you're saying that per insurance co more work should have been performed.  So which is it?  Also, what does your Explanation of Benefits say ?  If you don't access to it on-line anymore then you can have the insurance co mail it to you.  

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ach1199 said:   
jesrf said:   Thanks for the responses. To clarify, the insurance felt that more work was necessary not less. In fairness it's been 3 years and it seems fine. I do agree, probably time to find a new dentist, but I've been busy. And I only go ages times a year
  This is so confusing.  First you said that the insurance co said that the work should not have been performed and now you're saying that per insurance co more work should have been performed.  So which is it?  Also, what does your Explanation of Benefits say ?  If you don't access to it on-line anymore then you can have the insurance co mail it to you.  

  

It's a case of the insurance not agreeing with the diagnosis codes.  The irony is that it sounds like they are arguing a more expensive procedure was warranted (pull tooth and put in implant??).

Medical Reviews have become a matter of routine business for medical providers.  Many people don't realize that insurance companies are mandating that their entire case file be mailed/faxed god knows where.  I have found that many of the initial follow ups I receive from medical reviews aren't even from medical professionals.

If the provider is in network, nearly every contract prohibits the provider from billing the patient for work deemed not medically necessary.  Most likely, the provider messed up the appeals process and is out the money.  OP should just hand over copies of the EOB's showing the denial reason.

If the provider is out of network, all negotiation of prices is between the provider and the patient.

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LorenPechtel;19846484 said:If the dentist is in network a determination that it wasn't necessary normally means they don't get paid.

Overall, I rather suspect you're looking at a case of a sloppy accounting department. I've hassled with such stuff before--there's a bill in the system that is invalid for some reason. Sometime down the road they recheck their data and the old bill gets resurrected. Strange how they are so much better at figuring out they're owed money than figuring out they aren't owed money.

  As a followup to this if the dentist is out of network they will want to balance bill you, meaning you pay for anything the insurance company denied. Some states have laws preventing this or limiting the amount.



I don't understand how the crown is unnecessary in this case. If the root is too close what are they going to do? A bridge?

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Maybe we have a dentist on the forum that can comment. 

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Probably should have had a crown lengthening procedure where a little bone is removed if the edge of the crown was too close to the "jaw bone."

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The dentist may have been trying to be less aggressive but since there is a technical standard, the insurance may be holding him to it so that they can save money. Cases like this just add to my frustration that our healthcare system isn't single payer.

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jesrf said:   Thanks for the responses. To clarify, the insurance felt that more work was necessary not less. In fairness it's been 3 years and it seems fine. I do agree, probably time to find a new dentist, but I've been busy. And I only go ages times a year
  
Seems like he did a better job on your tooth than the insurance adjusters would have done if you let them work on you.
The question is, who dropped the ball on making the patient's insurance pay up, the provider or the patient?

If it's the patient's responsibility to get a viable procedure covered by his insurance, then just pay the doctor, he did the job you hired him for.

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bucksandreds2185 said:   The dentist may have been trying to be less aggressive but since there is a technical standard, the insurance may be holding him to it so that they can save money. Cases like this just add to my frustration that our healthcare system isn't single payer.
  There would still be private practitioners under single payer. How would it change the situation?

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OK, thanks to everyone, just a final update. I called the Insurance company on Friday, explained it. They said no problem, we will send him a cease and desist letter, he is in Network and is not allowed to bill me. 

They are sending me a copy and they said if he tries to collect again to call them, they'd resolve it. 

So for once, plus one to the insurance company, thanks to all of you who chimed in.

To those who asked, yes the insurance company felt MORE should have been done, not less (weird I agree) but without going into detail they feel the procedure while it may last a few years its not going to hold up over time. 

Take good care of your teeth....

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JepJepJep said:   Why would you go back to a dentist who (according to your insurance) is performing unnecessary procedures on you?

It is time to find a new dentist.

  Here lies the problem with healthcare currently....

Why is this not the insurance companies fault for failing to pay for a procedure the professional said needs conducted?  Why does everyone want to believe the insurance company and not the doctor?

I see this as an Emergency Physician.  Patients come see us all the time for various reasons, sometimes it IS a cold or stubbed toe.  They think its an Emergency, they couldn't find care somewhere else, whatever the reason... They came and saw me in the ER.

Fast forward 3-6 months, insurance company denies charges because 'this clearly wasn't an emergency'.   So now, the doctor/hospital can try to go get money from the patient who of course is going to say "HA, pound sound, talk to the insurance company."

Another option, 56 year old has chest pain.  Comes to the ER, is a smoker, has diabetes, gets a HUGE workup and an heart attack is ruled out.  Turns out it was the two boxes of hot tamales.  Bad case of heart burn.   Insurance company denies, NOT AN EMERGENCY.

I'll get off my soapbox.

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troutmd said:   JepJepJep said:   Why would you go back to a dentist who (according to your insurance) is performing unnecessary procedures on you?

It is time to find a new dentist.

  Here lies the problem with healthcare currently....

Why is this not the insurance companies fault for failing to pay for a procedure the professional said needs conducted?  Why does everyone want to believe the insurance company and not the doctor?

I see this as an Emergency Physician. ...

I'll get off my soapbox.



In this case it's easy to believe the insurance because they are actually saying that MORE work was necessary. So it's doubtful they were trying to get out of paying the bill.

The dentist in question and the insurers have a contract that make it not the insurers fault to pay.

Dental offices are a lot different than emergency rooms.

But I appreciate your point about the situation in emergency rooms.

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FWIW I have a very meticulous dentist and for a long time he didn't take any insurance at all as in-network. Eventually he started taking some DMO coverage, and it included mine (MetDental). Metdental is very much a controlling party compared to previous insurance I have had -- they want copies of xrays, full treatment plans ect... their procedure rates are quite low and they do NOT allow the dentist to bill any more than what they say is billable. (in the past my old plan paid out of network, actually quite a bit more than Met but the dentist could and did charge his full rate so I actually paid more and in turn expended my benefits faster as well) A few crowns on my old plan and I was done for the year.

I had a root that was being worked on and the dentist tried to "save it" versus a full extraction. He did that *knowing* that if it failed to save the tooth that he would not get paid for it. So he did the root, failed, and then only got paid for a simple extraction. Two visits and he was paid $65. He is/was a great dentist who does not let Met push him around TOO much, but still has to follow their rules on billing. I haven't had any work done for quite a few years now, may have to start another round soon. (been in and out of town and recent employer dental has been pretty basic)

Don't know how well my new dental works, don't think I ever had United Healths version.

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stanolshefski said:   
bucksandreds2185 said:   The dentist may have been trying to be less aggressive but since there is a technical standard, the insurance may be holding him to it so that they can save money. Cases like this just add to my frustration that our healthcare system isn't single payer.
  There would still be private practitioners under single payer. How would it change the situation?

  Because imho, this may be a situation where the insurance is finding a technicality to avoid paying and the dentist probably spent $200-$300 on supplies including paying for the crown to be made as well as 1-2 hours of work and overhead and he's getting $0. 

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troutmd said:   
 
I'll get off my soapbox.

  A dentist office have plenty of time to get pre-approval.  My dentist had to take pictures, do write-up, get rejected, get more pictures and eventually get the approval to put crowns on.  The entire time he also made sure I understand I can just pay out of pocket for the whole thing.

In OP's case, it's absolutely the fault of the dentist's office.

rated:
troutmd said:   
JepJepJep said:   Why would you go back to a dentist who (according to your insurance) is performing unnecessary procedures on you?

It is time to find a new dentist.

  Here lies the problem with healthcare currently....

Why is this not the insurance companies fault for failing to pay for a procedure the professional said needs conducted?  Why does everyone want to believe the insurance company and not the doctor?

I see this as an Emergency Physician.  Patients come see us all the time for various reasons, sometimes it IS a cold or stubbed toe.  They think its an Emergency, they couldn't find care somewhere else, whatever the reason... They came and saw me in the ER.

Fast forward 3-6 months, insurance company denies charges because 'this clearly wasn't an emergency'.   So now, the doctor/hospital can try to go get money from the patient who of course is going to say "HA, pound sound, talk to the insurance company."

Another option, 56 year old has chest pain.  Comes to the ER, is a smoker, has diabetes, gets a HUGE workup and an heart attack is ruled out.  Turns out it was the two boxes of hot tamales.  Bad case of heart burn.   Insurance company denies, NOT AN EMERGENCY.

I'll get off my soapbox.

  
Because it's a huge conflict of interest on both sides.

One side would argue to the end of time that every single procedure is "medically unnecessary" if they could. WHAT? Anethesia? Come on you could sit through that surgery just fine without it you wimp! They benefit from the least amount of use

The other side would argue to the end of time that every single test and every single procedure is medically necessary IMMEDIATELY or you will die! They benefit from maximum amount of use.

Each side is the right side some times.

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