Understanding Dental Insurance Billing: Why The Wait On Claims?

There are many reasons why a dentist might not have billed your insurance. Firstly, it is important to understand that there is no obligation or relationship between the dentist's office and the insurance company. The financial obligation remains between the dentist and the patient. Therefore, it is the patient's responsibility to pay the dentist for the services rendered, and the insurance company's responsibility to pay the patient for certain dental benefits.

In some cases, the insurance company may deny benefits for services rendered, leaving the patient responsible for the full payment. Additionally, insurance rarely pays 100% for any treatment, so there is usually an out-of-pocket cost for the patient. It is also possible that the dentist's office simply forgot to bill the insurance company or missed the deadline for submitting claims.

If you find yourself in a situation where your dentist has not billed your insurance, it is recommended that you first contact the dentist's office to understand their billing process and determine if they will be billing your insurance company. If they are unable or unwilling to bill your insurance, you may need to submit the claims yourself or seek legal advice if you believe you are not responsible for the full payment.

The dentist may have forgotten to bill the insurance company

It is possible that the dentist has forgotten to bill the insurance company. This is supported by the fact that the dentist's office confessed that they never submitted the claims. However, it is important to note that the dentist still wanted the patient to pay, even though they were informed that it was too late to process the claims. The patient was told that the dentist only billed the insurance company as a courtesy and that it was the patient's responsibility to send the claims if the dentist didn't do so.

In this case, the patient has a few options. They can try to resolve the issue with the dentist directly, or they can seek legal assistance. The patient could also try to get a written statement from their insurance company stating that the dentist needs to appeal the claims and that the patient is not responsible for the bills. This could be helpful if the patient decides to take legal action, such as taking the case to a small claims court.

It is important to note that the patient should not ignore the bill, as it could affect their credit score and financial standing. The patient should also be proactive in resolving the issue and keep records of all communication with the dentist and insurance company.

The insurance company may have denied the claim

There are many reasons why an insurance company may deny a claim. It is important to note that the financial obligation remains between the dentist and the patient. The dentist's office may assist in understanding your insurance benefits, but the patient remains the primary responsible party to pay for services.

One of the most common ways insurance companies ensure soaring profits is to collect monthly premiums from their members and then deny as many claims as possible by referring to the literature in a patient's contract. This results in decreased payouts and increased profits for the insurance company.

• Lack of information from the provider: At least 50% of dental claims for basic and major services will be placed on pending status and sent back to the dental office, requiring additional information for the claim to be considered for payment.
• Limitations, exclusions, and frequencies: All dental plans are not created equal. Most dental plans are based on what a patient's employer has agreed on with the dental plan provider. Limitations such as annual or lifetime maximums ensure control over how much is paid out on a dental policy.
• Contractual denials: Some contracts don't cover certain services, usually cosmetic procedures. Contractual limitation denials are delayed or denied due to limitations in the contract based on age, frequency, or waiting periods.
• Incorrect or missing patient information: This includes name, address, date of birth, etc.
• Incorrect dental codes: It is necessary to include the correct, current code set to identify the diagnosis, services rendered, and procedures performed.
• Supporting documents missing: This includes bills, x-rays, etc.
• Claim submitted after the last submission date: Most PPO plans require that the claim be submitted within one year from the date of service.
• Out-of-network dentist: If the dentist is out-of-network, the insurance company may deny the claim.
• Pre-authorization: Pre-authorization can be a valid reason for claim denial and is dependent on the dental insurance plan.

If your claim has been denied, you can analyze the claim denial reason mentioned in the Explanation of Benefit (EOB) letter received from the insurance company. You may then resubmit the claim after making the required corrections as per the insurance company's guidelines. If your claim is denied for an incorrect reason, you can raise an appeal.

The dentist may not be in-network with the insurance company

When a dentist is in-network, it means they have a contractual agreement with the insurance company. This means that the insurance company has already negotiated the fees on the patient's behalf, and the dentist can only charge the fees that have been agreed upon. However, not all dentists are in-network with insurance companies.

If your dentist is out-of-network, they are not obligated to write off any disallowed charges, and you may end up paying more out-of-pocket. In this case, your insurance company may deny benefits for services rendered, leaving you responsible for the full payment.

It is important to clarify whether your dentist is in-network or out-of-network with your insurance company to avoid unexpected costs. Dental offices are not obligated to walk you through your insurance plan, but it is always a good idea to understand your coverage before seeking treatment.

The patient may be responsible for out-of-pocket costs

For example, if a patient has a health insurance plan with a deductible, they must pay the full cost of services until they reach this amount. Once the deductible is met, the patient may be responsible for coinsurance, which is a percentage of the cost of a service that the patient pays. Copayments are fixed fees that a patient pays for certain medical services or medications, regardless of the total cost.

In some cases, patients may receive a surprise medical bill, which is an unexpected bill from an out-of-network provider or facility. This can occur if the patient's insurance plan does not cover the entire out-of-network cost, resulting in the patient owing the difference.

It is important for patients to understand their insurance plan and any out-of-pocket costs they may be responsible for to avoid unexpected medical bills. Healthcare providers should also communicate these costs clearly to patients to improve transparency and patient satisfaction.

The dentist may have provided incorrect information about insurance coverage

It is possible that the dentist provided you with incorrect information about your insurance coverage. This could be due to a misunderstanding or miscommunication between the dentist and your insurance company. It is important to clarify the details of your insurance coverage before proceeding with any dental treatment.

In some cases, the dentist may have made an honest mistake in interpreting your insurance policy. Dental insurance can be complicated, and it is not uncommon for even experienced dentists to make errors when determining what treatments are covered. However, this does not relieve them of their responsibility to provide accurate information to patients.

Additionally, there may be instances where the dentist intentionally misrepresented your insurance coverage to pressure you into agreeing to a particular treatment. This is a form of fraud and is unethical and illegal. If you believe this to be the case, you should seek legal advice and consider filing a complaint with the appropriate regulatory body.

To avoid such situations in the future, it is advisable to carefully review the details of your insurance policy and confirm coverage with your insurance provider before proceeding with any dental treatment. It is also recommended to get a second opinion from another dentist, especially if you are unsure about the recommended treatment or if it is not covered by your insurance.

Frequently asked questions