What Is Balance Billing in Dental Insurance?
Navigate dental insurance effectively. Learn to prevent unexpected balance bills and gain control over your out-of-pocket dental care expenses.
Balance billing in dental insurance occurs when a healthcare provider bills a patient for the difference between the provider’s charge and the amount the insurance company pays. This practice can lead to unexpected financial burdens for patients.
What Balance Billing Is and Why It Happens
This amount is separate from the patient’s standard co-payment, deductible, or co-insurance responsibilities. For instance, if a dentist charges $200 for a filling, but the insurance only pays $150, the remaining $50 could be balance billed to the patient.
The distinction between in-network and out-of-network providers is central to understanding balance billing. In-network providers have a contractual agreement with the insurance company, agreeing to accept a negotiated rate, often called the “allowed amount” or “contracted rate,” as full payment for covered services. These agreements typically prohibit balance billing for covered procedures, excluding the patient’s agreed-upon co-pays, deductibles, or co-insurance.
Out-of-network providers, conversely, do not have such contracts with insurance companies. They are not bound by negotiated rates and can charge their own fees for services. The insurance company may then pay a portion based on what it deems “Usual, Customary, and Reasonable” (UCR) rates for that service in a specific geographic area. If the out-of-network provider’s charge exceeds the insurance company’s UCR payment, the patient can be balance billed for the difference, in addition to their deductible or co-insurance.
Consider a scenario where a dental procedure costs $1,000. An insurance company might determine the UCR rate for that procedure is $800 and cover 80% of that UCR amount, paying $640. If the dentist is out-of-network and charges the full $1,000, the patient would be responsible for the $160 difference (20% of the UCR) plus the additional $200 that exceeds the UCR rate, totaling $360. This illustrates how balance billing can significantly increase out-of-pocket costs.
Proactive Steps to Avoid Balance Billing
Verifying if your chosen dental provider is in-network with your specific dental insurance plan is a primary step. Network statuses can change, so confirming this information before each appointment is advisable.
Understanding your dental plan benefits is another important proactive measure. Patients should review their plan’s Summary of Benefits and Coverage (SBC) or contact their insurance provider directly. This helps clarify details regarding deductibles, co-insurance percentages, annual maximums, and how out-of-network benefits, if any, are calculated, often based on UCR rates. Knowing these specifics helps patients anticipate their financial responsibility.
For more extensive dental work, requesting a pre-treatment estimate or pre-authorization from the dental office is advisable. The dental office can submit a proposed treatment plan to the insurance company, which then provides an estimate of what it will cover and the patient’s potential out-of-pocket costs before the procedure begins. This process offers clarity and allows patients to budget accordingly.
Patients should also engage in clear communication with their dental office regarding billing practices. Asking about estimated out-of-pocket costs before treatment can prevent surprises. This direct conversation helps ensure transparency and confirms understanding of all potential charges from the provider.
What to Do If You Receive a Balance Bill
Upon receiving a balance bill, the first step is to review your Explanation of Benefits (EOB) from your insurance company. The EOB details the provider’s original charge, the amount the insurance covered, and the portion designated as the patient’s responsibility, such as deductibles or co-insurance. Comparing the EOB with the dental bill helps identify any discrepancies.
Next, contact the dental provider’s billing department to clarify the charges. Request an itemized bill to understand each service and its corresponding cost. If the provider is in-network, it is appropriate to inquire why a balance is being billed, reminding them of their contractual agreement with your insurer.
After speaking with the provider, contact your dental insurance company to discuss the bill and your EOB. The insurance representative can help explain the payment breakdown, confirm the provider’s network status, and clarify if the bill represents a prohibited balance bill or a legitimate patient cost. They can also provide guidance on next steps.
If the issue remains unresolved after communicating with both the provider and the insurer, further action may be necessary. Patients can consider filing a complaint with their state’s department of insurance or a relevant consumer protection agency. Maintaining detailed records of all communications, including dates, times, and names of individuals spoken with, is important throughout this process.