Dental Insurance

[okeydokey]

I am having a disagreement with the Orthodontist office. My son needs to start his treatment and our dental I durance is pretty pricey but has the best coverage. On the website, it says that for braces for adolescents, we pay 1600 for two years of treatment, fixed or removable appliances. The dentist office quoted us 2700 for our share of treatment. Even if we pay the retainer they use that is not covered by insurance, that cost is 450. So how do the insurance companies get away with saying one thing on the website and something else in reality?

I sent the dentist a link to the I durance coverage page, but haven't heard back yet.

 

[usd2bmd]

I am having a disagreement with the Orthodontist office. My son needs to start his treatment and our dental I durance is pretty pricey but has the best coverage. On the website, it says that for braces for adolescents, we pay 1600 for two years of treatment, fixed or removable appliances. The dentist office quoted us 2700 for our share of treatment. Even if we pay the retainer they use that is not covered by insurance, that cost is 450. So how do the insurance companies get away with saying one thing on the website and something else in reality?

I sent the dentist a link to the I durance coverage page, but haven't heard back yet.

I'm confused as to how the insurance company knows how much you will pay. How is it that they know what the dentist will charge? Did they send in a predetermination form? Normally they state what they will cover. The limit on mine was $1000.

When my daughter was coming up to the age of needing them my husband and I both purchased dental insurance through our employers and they both covered up to their limit. then we were responsible for the rest.

 

[dreamin_disney]

get a printout and call the insurance. Sometimes if codes are wrong insirance will reject it.

Example: ortho office told us insurance will only pay a portion for the xrays. So we turn in paperwork and it was denied.
-First reason was because we had dual coverage and dh was the primary for dd. Even though his didnt have ortho, i had to redo paperwork and send it to his, wait for rejection. then resend it back to my insurance.

I sent it back to mine and they rejected the full amount. When I called to ask about it , I was told a very small portion would be covered, less than what ortho told me. So I called back and talked to another person and was told it was denied because they doubled charged me, paperwork showed xrays were done twice. Dh and I went back and talked to ortho and she called and it went back and forth and the codes were wrong. Once they told ortho what the correct codes were it was fixed and the full amount of xrays were covered to our surprise.

Then when I recieved my dental insurance paperwork I noticed ortho over charged us $412 more then what the insirance agreed to pay (insurance gets a discounted price). Then ortho said it didnt cover the herbts but the paperwork showed it was included in the price they gave us.

So I ended up saving $650 by calling the insurance and going over the ortho printout.

BTW- my insurance only paid $1500 and I paid the rest

 

[tvguy]

You sure by "we pay " the insurance company isn't saying that they, the insurance company will pay $1,600 of the treatment, not you?

 

[tlmcma]

Sounds to me like your maxiumum benefit is $1600 - anything charged over that amount would be the patient's (or parent's in this case) responsibility. The insurance company would have no way of putting on their website how much you would be paying out of pocket - every orthodontist is different in what they charge, and every treatment has a different cost. They most likely are referring to what THEY will pay towards the braces - which is $1600 total . For my kids - the total charge was between $3500 and $6000 each for 2 years of braces. $1600 would be a bargain!

 

[disneychrista]

You sure by "we pay " the insurance company isn't saying that they, the insurance company will pay $1,600 of the treatment, not you?

I agree with tvguy.
Usually, dental/vision insurance companys will list maximum benefits amounts, not OOP. So If treatment is $4,000, they pay $1,600 and you owe $2,400.

 

[tar heel]

It sounds to me like your insurance is saying your maximum is $1,600, which is more than most of us have for orthodontia. $1,000 is pretty standard.

 

[disneysmyhappyplace]

Our insurance company states the maximum benefit is $1900 per child under 18. That meant they would pay $1900 of the total. However don't be expecting one lump sum. They usually pay out on a monthly or yearly basis. In our case my son had his braces put on in February where I paid the entire bill of $3900. Well we received on lump payment of $500 from the insurance company and then we receive $70 reimbursement each month he is seen. So if we skip a month in being seen we don't get paid. So his treatment plan is for about a year and a half we will not get back the full $1900 in reimbursement. Tricky how these insurance companies work

 

[okeydokey]

Sounds to me like your maxiumum benefit is $1600 - anything charged over that amount would be the patient's (or parent's in this case) responsibility. The insurance company would have no way of putting on their website how much you would be paying out of pocket - every orthodontist is different in what they charge, and every treatment has a different cost. They most likely are referring to what THEY will pay towards the braces - which is $1600 total . For my kids - the total charge was between $3500 and $6000 each for 2 years of braces. $1600 would be a bargain!

The column says YOU Pay. The price is 1580. It implies that the max the customer pays is 1580, doesn't it.

Here is where I found it:

http://www.myflorida.com/mybenefits/Health/Dental_Plans/Dental_Prepaid_new.htm

The dentist said that the insurance would actually pay a bit over 2000 the way she figured it.

 

[vicki_c]

The column says YOU Pay. The price is 1580. It implies that the max the customer pays is 1580, doesn't it.

Here is where I found it:

http://www.myflorida.com/mybenefits/Health/Dental_Plans/Dental_Prepaid_new.htm

The dentist said that the insurance would actually pay a bit over 2000 the way she figured it.

That's a lot clearer now. That is different than the type of plan everyone else is mentioning, because it says right at the top "you pay a SPECIFIC amount" based on services used. So I agree it means YOU the customer will pay that exact amount in the column. Since you're disagreeing with the dentist, you should just call the dental insurance company directly and tell them what you're being told. They should be able to tell you what you will pay according to their coverage allowances and explain if its different than what they show on the website.

 

[wiigirl]

It sounds to me like your insurance is saying your maximum is $1,600, which is more than most of us have for orthodontia. $1,000 is pretty standard.

Me too...I have always heard aroun $1k.

 

[eeyoresmom]

hmmm. I live in a different state, so not sure if this applies, but are you sure the orthodontist you are using is participating fully in your dental plan? My dentist accepts my dental plan, but is "out of network" somehow so I pay a bit more for his services than I would for the fully participating dentists.

 

[okeydokey]

hmmm. I live in a different state, so not sure if this applies, but are you sure the orthodontist you are using is participating fully in your dental plan? My dentist accepts my dental plan, but is "out of network" somehow so I pay a bit more for his services than I would for the fully participating dentists.

No, he is on the in network list. I called again this morning and left a voicemail for the insurance lady. We shall see.

 

[HM]

I'm having trouble understanding the original post.

The term "we" in this sentence, "we pay 1600 for two years of treatment, fixed or removable appliances" .. is that the insurance company or the policyholder? It sounds like its the insurance company to me. If that is the case, that is all they will pay. Anything else above that would be covered by you out of pocket. So if your child's orthodontia is going to be $5000, you'll be paying $3400.

The way it worked for us. The insurance company says that they will pay a total of $1500 for each child's orthodontic treatment. Our first child's treatment was $4200, our second was about the same though her's was longer, but got a sibling discount.
At both orthodontists we went to for evaluation, there was no charge for the initial evaluation and cost analysis.

Your first visit with the chosen Ortho, where they do the x-rays and record keeping are not covered (I don't recall how much we paid for this...maybe $300) and we paid that upfront.

Our orthodontist has several options for payment. We chose to put in a large downpayment of what I think was 1/3 of the final cost and then payments each month after for about two years taken directly from our checking.

The insurance company was sent all the information about the treatment and costs. They paid a portion of the initial 1/3 payment and then divided what was left of the $1500 and sent those payments in the following months to us by check.

Does that help at all?

 

[angierae]

For my daughter's braces, it worked like this. Our insurance covered a max of $1800, lifetime, for orthodontic services. The orthodontist we went with (we had three consults with three different orthodontists, including xrays. We paid nothing at all for these consults) charged $8000, total, for braces, retainers, follow-up services, etc.

Our total bill was $6200. We got 10% off for paying it all up front instead of charging it on Care Credit, so we cut them a check for $5580. Our insurance paid out the $1800 in monthly payments over three years (that's how long the orthodontist estimated her treatment would take.) We did not have to pay the insurance portion, but if we lost the insurance before it was paid off, we'd be responsible for the balance.

 

[okeydokey]

The website clearly says YOU PAY and that is what our out of pocket should be. For example for cleanings and x-rays is says $0. We pay $0 out of pocket for those expenses. For braces our cost should be 1580 out of pocket. I posted the link in a previous post.

I did get a call back from the ortho. She said that the insurance states the co-pay as an enticement to get you to pick them, but they do not cover class 2 braces at that amount, nor do they cover crossbite at that amount and that is the treatment plan for my son. Of course that info is probably buried in the contract language somewhere. She did say our insurance is the best coverage, which I knew and is why we chose to pay for it. It is around 70 a month for the family.

Overall, the cost was 4800, of which we pay 2700. That includes the adjustable retainers and the years of follow up checks after the braces come off. Overall, I can't complain. I just wish the insurance companies operated in a more transparent way.

 

[vicki_c]

The website clearly says YOU PAY and that is what our out of pocket should be. For example for cleanings and x-rays is says $0. We pay $0 out of pocket for those expenses. For braces our cost should be 1580 out of pocket. I posted the link in a previous post.

I did get a call back from the ortho. She said that the insurance states the co-pay as an enticement to get you to pick them, but they do not cover class 2 braces at that amount, nor do they cover crossbite at that amount and that is the treatment plan for my son. Of course that info is probably buried in the contract language somewhere. She did say our insurance is the best coverage, which I knew and is why we chose to pay for it. It is around 70 a month for the family.

Overall, the cost was 4800, of which we pay 2700. That includes the adjustable retainers and the years of follow up checks after the braces come off. Overall, I can't complain. I just wish the insurance companies operated in a more transparent way.

Well that explains it then. They list your responsibility for the "plain vanilla" orthodontics as a marketing tool, but if you need anything different than that, our number will be different. To all the others, the OP has a different type of insurance than the traditional plans everyone else is describing. You can see that in the link she posted. I had not seen that type of plan before where the patient responsibility was stated up front (even though you've determined it might not be that).

 

[HM]

Well that explains it then. They list your responsibility for the "plain vanilla" orthodontics as a marketing tool, but if you need anything different than that, our number will be different. To all the others, the OP has a different type of insurance than the traditional plans everyone else is describing. You can see that in the link she posted. I had not seen that type of plan before where the patient responsibility was stated up front (even though you've determined it might not be that).

Thanks. I missed the link. Interesting.

I wonder how many people have a "plain vanilla" ortho plan. Every mouth is so different. Even how the orthodontist plans to treat can be different. The first guy we went to with our son, wanted to pull teeth. The second one said that it was very likely that would not be necessary (and it wasn't). His teeth turned out beautifully.

 

[okeydokey]

Thanks. I missed the link. Interesting.

I wonder how many people have a "plain vanilla" ortho plan. Every mouth is so different. Even how the orthodontist plans to treat can be different. The first guy we went to with our son, wanted to pull teeth. The second one said that it was very likely that would not be necessary (and it wasn't). His teeth turned out beautifully.

A friend just went through the same thing. The first person wanted to add implants to create the eye teeth her son was missing, the second guy said he could work with what he had. It's hard to know sometimes what is best. Glad your son's worked out well.

 

[clanmcculloch]

Check out the footnote.

Copays do not include pre-exam and retention​

Pre-orthodontic as defined in the 4th code under orthodontia:

Pre-orthodontic treatment visit (consult/records/exam)​

Retention as defined in the 5th code under orthodontia:

removal of applicances, construction and placement of retainer(s))​

It seems like they're contradicting themselves with they state comprehensive treatment and then have that footnote and description of retention. IMO that's underhanded but they can probably get away with it since nowhere is it detailed what's included in that comprehensive coverage and they do have that footnote.

Comprehensive orthodontic treatment of adolescent dentition (full treatment case up to 24 months - including fixed/removable appliances)​

$1580 + + 80 (pre-orthodontic) + $250 (retention) + $450 (retainer) = $2360

$2700 - $2360 = $340 which looks to be the additional year of follow-up.