Can a Dentist Charge More Than Insurance Allows?

Understanding the intricacies of dental billing and insurance is important for managing healthcare expenses. Navigating dental costs can be complex, often leading to questions about financial responsibility. Knowing how dental insurance operates helps individuals anticipate out-of-pocket costs and make informed decisions about their dental care.

Understanding Dental Insurance Terms and How They Affect Costs

Dental insurance plans utilize specific terms that directly influence a patient’s financial contribution to their care. The “allowed amount” refers to the maximum sum an insurance plan will pay for a covered service. This amount is often determined by the insurer’s fee schedule, which may be lower than the dentist’s standard charge.

Insurers also use “Usual, Customary, and Reasonable (UCR) Fees” to establish what they consider a fair price for a service in a particular geographic region. The “usual” fee is what a dentist typically charges, “customary” is the range of fees in a given area, and “reasonable” accounts for special circumstances. If a dentist’s fee exceeds the UCR, the patient may be responsible for the difference.

A “deductible” is the amount a patient must pay for covered dental services before their insurance plan begins to contribute. This amount typically resets annually, and some preventive services may be exempt from the deductible. For instance, if a plan has a $50 deductible, the patient pays the first $50 of covered services before the insurer starts paying.

“Co-payment,” or co-pay, represents a fixed amount a patient pays for a covered service, often at the time of the visit. Co-pays are usually a set price and can vary depending on the specific service received. Unlike deductibles, co-pays typically do not count towards meeting the deductible.

“Co-insurance” is the percentage of the cost of a covered service that the patient is responsible for after the deductible has been satisfied. For example, a plan with 80%/20% co-insurance means the plan pays 80% and the patient pays the remaining 20% of the allowed amount.

The “annual maximum” is the total dollar amount an insurance plan will pay for dental care within a benefit period, which is usually a calendar year. Once this maximum is reached, the patient becomes responsible for 100% of any additional costs for dental services until the next benefit period begins. Annual maximums typically range from $1,000 to $2,000.

In-Network Versus Out-of-Network Dentists and Billing

Whether a dentist can charge more than insurance allows largely depends on if the dentist is “in-network” or “out-of-network” with a patient’s insurance plan. These distinctions are rooted in contractual agreements between providers and insurance companies.

In-network dentists have a direct contract with the insurance company. They agree to accept the insurer’s “allowed amount” as full payment for covered services. This contractual agreement generally prevents in-network providers from billing the patient for the difference between their full fee and the allowed amount. Patients are still responsible for their deductible, co-payments, and co-insurance as stipulated by their plan. For example, if an in-network dentist’s fee is $100 and the allowed amount is $80, the dentist agrees to write off the $20 difference, and the patient pays only their share of the $80 allowed amount.

Out-of-network dentists, in contrast, do not have a contract with the patient’s insurance company. These providers are not bound by the insurer’s fee schedule and can charge their full fee for services rendered. This fee may be higher than the insurance company’s allowed amount or UCR for the same service. In such cases, the patient’s insurance plan will typically pay a portion of the allowed amount directly to the patient or the dentist.

“Balance billing” is a practice almost exclusively associated with out-of-network providers. It occurs when an out-of-network dentist bills the patient for the difference between their full charge and the amount the insurance company pays. For instance, if an out-of-network dentist charges $200 for a service, but the insurance company’s allowed amount is $150, the patient might be billed for the remaining $50 even after the insurer pays its portion. This $50 is the “balance” that the patient is responsible for, in addition to any deductible or co-insurance. Patients often face unexpected higher out-of-pocket costs when using out-of-network providers because of this practice. While generally legal for out-of-network dental care, balance billing can lead to significant surprise bills.

Addressing Unexpected or Higher-Than-Expected Dental Charges

Receiving a dental bill that appears unexpectedly high can be concerning. The first step involves obtaining and carefully reviewing the Explanation of Benefits (EOB) from the dental insurance company. The EOB is not a bill, but a statement detailing how the claim was processed. It will outline the services rendered, the dentist’s submitted charges, the allowed amount, the amount the insurance paid, and the patient’s responsibility, including any applied deductible or co-insurance. Checking the EOB against the dental office’s bill helps ensure consistency in reported charges and payments.

Following the EOB review, communicating directly with the dental office’s billing department is advisable. Patients can inquire about specific charges, verify procedure codes, and seek clarification on why the bill reflects a particular amount. This conversation can often resolve discrepancies or provide a clearer understanding of the charges. The dental office can explain their billing practices and how the insurance payment was applied.

A subsequent step involves contacting the dental insurance company. Patients should be prepared to discuss their coverage, confirm the allowed amount for the services received, and understand how their claim was processed. It is important to ask about any denials or reductions in payment and the specific reasons for those decisions. Maintaining a record of all communications, including dates and names of representatives, is beneficial.

If there appears to be an error in claim processing or a misapplication of benefits, patients may have the option to pursue an appeal with their insurance company. Most insurers have a formal appeal process, often with multiple levels of review. This typically involves submitting a written request for reconsideration, providing relevant documentation such as the EOB, clinical notes, or X-rays. Understanding the reasons for any denial, as stated on the EOB, is important before initiating an appeal.