Orthodontic costs

[Jaime4004]

So DD8 recently had a palate expander and a space maintainer put in (and headgear in a few weeks), to the cost of $3370. Our dental pays 50%, up to a lifetime max of $1500 (that's another topic, since we haven't even hit braces yet.) So I received the statement from the dental insurance that the "accepted fee" for what she had done was $1685. So they paid 50% of that rate, instead of the $3370. So we did not receive the full $1500 towards it that I, and the orthodontist office, were expecting.
Does this sound right? I know with medical claims, the MD office bills the insurance, they only pay their contracted rate, and the office eats the difference, minus any copays. I know that I owe the difference, I signed paperwork that I would pay whatever the insurance did not. But does this usually happen with dental, that the office bills way more than insurance will pay, or did I pick a shady office?

 

[DizBelle]

"Reasonable and customary" strikes again...

 

[Hannathy]

It happens. Some practices charge a lot more for some procedures than others. That is why it is always good to check with your insurance before any costly treatments that aren't out right emergencies.


I wouldn't necessarily call them shady, just expensive.

 

[smj2610]

does your dental insurance have a dental network? If they do and your provider is in the network you only need to pay up to the insurance allowance, if not it is correct that dental services has usual and customary allowance the same as medical but the provider is not obligated to write off over the insurance allowed amount

 

[crazyme5kids]

Yeah that sounds right. My insurance paid out in stages until the $1500 was used up. We have new health insurance now under my husband, and it is paying the orthodontist the same way.

 

[smitch425]

does your dental insurance have a dental network? If they do and your provider is in the network you only need to pay up to the insurance allowance, if not it is correct that dental services has usual and customary allowance the same as medical but the provider is not obligated to write off over the insurance allowed amount

Exactly. This is how regular medical insurance works as well. If the Dr. is in-network, by contract they have to write off anything over the allowable charges. If they are not in-network, they can charge you whatever they want. Some plans have preferred in-network and those within the network that are not preferred but are still contracted. For example, at a preferred Dr. the insurance may pay 100%, but at a non-preferred Dr. it may only be 70%. Both will write off the excess, but with the non-preferred doctor you will pay more OOP. Then there are doctors who are not contracted at all, and in that case you will pay anything the insurance doesn't pay on.

 

[Jaime4004]

does your dental insurance have a dental network? If they do and your provider is in the network you only need to pay up to the insurance allowance, if not it is correct that dental services has usual and customary allowance the same as medical but the provider is not obligated to write off over the insurance allowed amount

Ah, that helps, thanks! The orthodontist is not in network. I did check into it before going and saw that she was covered by the insurance for 50%, up to $1500, which was all that I was concerned about. Had no idea that the insurance would decide how much was reasonable for that service. Live and learn. It's our first dealing with orthodontists, never even saw one myself.
DD actually loves the office, they seem really nice. Might have to price shop when it's time for the braces though....

 

[sparklynails23]

That's way too much for an expander and spacer, way too much. It would almost cover a set of braces in addition to the other stuff where I live.

 

[luvmy3jewels]

That's way too much for an expander and spacer, way too much. It would almost cover a set of braces in addition to the other stuff where I live.

I think I may need to move to your neck of the woods My oldest dd just got braces and we are paying $5750 which covers the standard braces and one retainer. My youngest dd will soon be entering the "phase 1" stage which is the expander and spacers and it is estimated to cost around $3,000. I agree with the pp that mentioned that dental insurance tends to pay what they estimate as reasonable and customary costs. I have yet to find a dentist or orthodontist that charges the fees that our insurance claims are reasonable and customary.

 

[ccgirl]

So DD8 recently had a palate expander and a space maintainer put in (and headgear in a few weeks), to the cost of $3370. Our dental pays 50%, up to a lifetime max of $1500 (that's another topic, since we haven't even hit braces yet.) So I received the statement from the dental insurance that the "accepted fee" for what she had done was $1685. So they paid 50% of that rate, instead of the $3370. So we did not receive the full $1500 towards it that I, and the orthodontist office, were expecting.
Does this sound right? I know with medical claims, the MD office bills the insurance, they only pay their contracted rate, and the office eats the difference, minus any copays. I know that I owe the difference, I signed paperwork that I would pay whatever the insurance did not. But does this usually happen with dental, that the office bills way more than insurance will pay, or did I pick a shady office?

Exactly. This is how regular medical insurance works as well. If the Dr. is in-network, by contract they have to write off anything over the allowable charges. If they are not in-network, they can charge you whatever they want. Some plans have preferred in-network and those within the network that are not preferred but are still contracted. For example, at a preferred Dr. the insurance may pay 100%, but at a non-preferred Dr. it may only be 70%. Both will write off the excess, but with the non-preferred doctor you will pay more OOP. Then there are doctors who are not contracted at all, and in that case you will pay anything the insurance doesn't pay on.

This is a very good explanation. Did you receive an EOB (Explanation of Benefits) prior to starting? I get one for every dental procedure so I know exactly how much the dentist is charging, how much is customary to pay and how much I will be resposible for. I never sign anything or give the go ahead until I know exactly how much I will be paying.

I would agree that sounds like an awful lot the dentist is charging and I am from a high COL area.

That is how insurance works 99% of the time. The insurance company plays a portion of the reasonable and customary rate. What if one dentist charges double another dentist. They are not just going to cough up the cash to the dentist that overcharges.

As you said, with Medical they pay the contracted rate if there is a contract. Not every provider has a contract. They might not take a certain insurance. Also, every provider/provider group has their own contract. WIth larger provider groups, they are able to negotiate better rates with the insurance companies.

Hope that helps.

 

[Poohforyou]

That's way too much for an expander and spacer, way too much. It would almost cover a set of braces in addition to the other stuff where I live.

My DD has braces now and they cost $5600. Just like a lot of other things price varies depending on where you live.

OP, the reasonable and customary is common with any dental work. If your lifetime max for orthodontics is $1500 you'll be able to recoup the balance when you DD gets braces.

 

[Jaime4004]

This is a very good explanation. Did you receive an EOB (Explanation of Benefits) prior to starting? I get one for every dental procedure so I know exactly how much the dentist is charging, how much is customary to pay and how much I will be resposible for. I never sign anything or give the go ahead until I know exactly how much I will be paying.

I would agree that sounds like an awful lot the dentist is charging and I am from a high COL area.

That is how insurance works 99% of the time. The insurance company plays a portion of the reasonable and customary rate. What if one dentist charges double another dentist. They are not just going to cough up the cash to the dentist that overcharges.

As you said, with Medical they pay the contracted rate if there is a contract. Not every provider has a contract. They might not take a certain insurance. Also, every provider/provider group has their own contract. WIth larger provider groups, they are able to negotiate better rates with the insurance companies.

Hope that helps.

I did know how much I was going to pay, signed for it, worked out the monthly payments based on the balance. But that was based on the insurance paying $1500, but they only paid $750. I know i'll get the other $750 when she has braces, just wasn't expecting to pay it now!

I had to explain all i've learned from you guys to DH a few times, he wasn't getting it either.

Medical insurance has never been an issue because we stayed in-network due to the higher copays, not realizing that if we didn't they also could charge more for the same services and we'd be stuck with it.

 

[tasha99]

DS's braces were $7500 (and that was my second estimate). There was a coupon, so they ended up being $6300, but still--I think braces in the lower 48 are a whole lot cheaper, just like everything else.

 

[SaraJayne]

DS's braces were $7500 (and that was my second estimate). There was a coupon, so they ended up being $6300, but still--I think braces in the lower 48 are a whole lot cheaper, just like everything else.

Yikes! DS's were around $4500 or $5000 (can't remember, it was two and a half years ago! LOL) and that includes everything (spacers, expanders, braces, retainer, etc). We should not have to pay another dime for the rest of his treatment (unless he loses a retainer).

 

[mjkacmom]

Some of mine just had expanders, $850, but don't you worry about not getting your full $1500. Both dd15 and ds14 averaged around $6500 total. That $1500 is a drop in the bucket. Did you get an estimate for the braces yet?

 

[pilesoflaundry]

The way our's works is they do not pay the full lifetime cap at once, they pay a percentage of all services rendered until the $1500 cap is met.

I have to get work done on all 3 kids but 2 of them need it more than the third one so I'm hoping we can squeak by with just doing it for 2 of them. I don't even want to know what it's going to cost us in the long run. 2 of them need major work.

 

[Jaime4004]

Some of mine just had expanders, $850, but don't you worry about not getting your full $1500. Both dd15 and ds14 averaged around $6500 total. That $1500 is a drop in the bucket. Did you get an estimate for the braces yet?

Didn't go there yet, I don't want to know. I think the braces are a few years off. I did joke with DH that maybe he could get another job before then so we have new insurance and a new lifetime max.
I have two other kids so i'm sure we'll spend the next several years of our lives in that office. I should put the balances on my Disney VISA so something good, other than straight teeth, will come out of it.

 

[mjkacmom]

Didn't go there yet, I don't want to know. I think the braces are a few years off. I did joke with DH that maybe he could get another job before then so we have new insurance and a new lifetime max.
I have two other kids so i'm sure we'll spend the next several years of our lives in that office. I should put the balances on my Disney VISA so something good, other than straight teeth, will come out of it.

If it makes you feel better, $1500 is one of the highest lifetime max's when it comes to dental insurance and orthodontia. All five of mine have been, because they all need braces, but thank goodness that, thanks to their different teething schedules, we are staggered (almost done paying for #2 and dd9's expander ).

 

[goofy!]

We lucked out on DS's braces. A new ortho came into town, just out of school and was setting up a practice. She offered a special of everything for $3,500 to start getting patients in.

We interviewed her and actually loved her. So, we decided to go with her instead of the high-priced ortho we used before.

DH's insurance had a $1,700 max and my part-time job's insurance had a smaller amount; $1,500. But with both insurances, I ended up only paying $300 out of pocket. And since her introductory prices were so low, the insurance had no problem with them.

He just got them off 2 weeks ago and his teeth look just as good as his sister's teeth that cost us $4,800 (with just DH's insurance) over 10 years ago. In fact, she was much more attentive to his teeth than the expensive, busy guy was.