I had a bit of a dental emergency about a month ago. One of my back teeth just started aching like crazy out of the blue. I went in to see my dentist and he ran a few tests, then determined that the tooth was likely cracked and the only fix for that was a crown. The ladies at the front desk ran all the numbers for me and quoted me my portion at just shy of $500. I wasn’t really prepared for it, but I made it happen because the tooth was bothering me so much I knew it couldn’t wait. In the end, he did up the crown in one visit for me. I left with the work totally done and I believed we were flush with the billing.
I should preface this by saying I do not question the doctor’s diagnosis. The crown is great and my tooth feels fine. It’s business as usual for me again. However, I received a notice from my insurance company that they were not going to pay their portion, and I’m more than a little miffed that I’m going to have to come up with several hundred dollars more. If they weren’t going to pay and the dentist was going to stick me with the extra portion, why didn’t they just say so from the start? At least then I could have prepared for the bill. Can they even do this or is there some rule that protects me from bills that aren’t mine to pay?
There are a couple different angles to address this from, but let’s start with the letter you received. It sounds like what you got was an “explanation of benefits” or EOB from the insurance company. They send those letters out to keep you informed about what they’ve paid, but they aren’t bills. Your dentist got one too, though his version usually comes with a check for the services performed.
When insurance companies don’t pay what an office is expecting, they usually follow up. If you check your sheet, you’ll probably see more details as to why they didn’t pay. Common causes are that a patient has reached their maximum, hasn’t reached a deductible, that the service was not a covered benefit, or that the office didn’t supply enough information to demonstrate you needed the treatment. If it comes down to one of the first three reasons then there’s probably not much the office can do about it. However, if it’s the latter, then the office is likely already “fighting” with the insurance company and has already supplied them with more information. You can call the office to see how they’re handling it, but it shouldn’t be considered a bill until the office is the one telling you that you owe.
That said, when emergency dental treatment is needed, the focus becomes getting you out of pain fast. There are things an office can do to get the insurance company to commit to an amount when there’s more time, such as requesting a pre-auth or getting a predetermination of benefits, but these can take weeks or more to process. In other words, there’s no real way to know what they’ll pay until they’re billed when you go in for any kind of emergency dental treatment.
Ultimately, the insurance is a “middleman.” Your dentist has agreed to treat you and you’ve agreed to pay him. They bill the insurance as a courtesy to you, but if the insurance company does not pay, you are responsible for covering the cost of treatment. Remember, that doesn’t mean they still won’t pay—you may not owe anything more. Check with your office to see what steps they’re taking.
This blog is sponsored by Dr. Steve Sirin. Dr. Sirin provides same-day appointments for dental emergencies in Elgin.