Help - out of network insurance charges - updated in first post

[Kassia]

My daughter has been going to the same in-network dentist for several years.  I took her for her cleaning appt. a few months ago and sent her back with the hygienist we knew while I waited in the waiting area (dd was almost 16 at the time).  After the appointment, a woman I had never seen came out with dd and said that dd had a few small cavities and we could make an appt. or the fillings could be done right then.  Dd told me she'd like to do it while she was there and that this was a different dentist and she liked her.  

I received the bill today and it was very high.  I called our insurance and discovered that the dentist who treated dd was not an in-network provider.  I called the dentist's office and was told our dentist had left and the dentist who treated my daughter is the new dentist at the office.  I was never notified of the change and had no way of knowing when I sent dd back for her cleaning that she wasn't going to be seeing the dentist we had always seen before.  Any time there has been a change of doctors or dentists at a practice, we've always received a notice saying who was leaving and who was replacing that person.  In this case, we assumed we were seeing the dentist we had always seen at that location.  When we made the appointment, the previous dentist was treating dd and we made the appointment thinking that it would be the same dentist.

Is there anything I can do about the bill?  DH is calling this a bait-and-switch because we had no knowledge of the change in providers/cost.  I am so upset - we owe almost $1,000!  

 

ETA:  I called the office today and the woman I spoke with in billing was very nice.  She explained that dd's appt. was at a crazy time of transition (I get the feeling that the other dentist left unexpectedly and they had to rush to bring in someone new) and that she would adjust the bill as if our insurance had covered it.  Fingers crossed that it all works out.  ?  

Edited October 8, 2018 by Kassia

[Storygirl]

Ugh, that's horrible! I think that is very poor practice on the part of the dentist. Ours always checks our coverage and has us sign to approve the estimated cost before doing work other than the standard cleaning.

I would definitely call the dentist office to complain. After that... I don't know. I'm sure there must be a dental board in your state that you could report this situation to.

[RootAnn]

I'd both appeal the insurance (which will probably be denied, but you can try it) and contact the dentist office. The dentist office might be willing to give you the in-network cost this one time since they didn't check for pre-approval and they likely DID know they weren't in network anymore. I'd try not to get upset, but just keep explaining to people & then asking for the next person up in the chain if they deny your request. I'd also ask if the new dentist was going to try to become in-network for your insurance. "My daughter liked the new dentist, but we certainly cannot afford to keep going if we are paying out of network costs..."

[J-rap]

Wow, that is horrible, and is one of the reasons why our insurance system drives me absolutely crazy.  I think I'd start with the dental office.  If they've covered you in the past, how in the world would you know that that had changed unless they told you?  I think they owe you this one and I'd fight it.  I might start by doing it gently, and just send a check for what it would have been if your insurance covered it, with a letter kindly explaining your reason while making them feel like the guilty party for not letting you know about the change.  I'd also suggest to them that they apply to be part of your insurance company so this won't happen anymore, because you've been happy with their service in the past. 

If their business department doesn't accept it, I'd go directly to the dentist and try.  

If that doesn't work, I'd go to the insurance company to see if they can step in, but they'll probably be the least helpful.

Good luck!

[Kassia]

8 hours ago, RootAnn said:

\"My daughter liked the new dentist, but we certainly cannot afford to keep going if we are paying out of network costs..."

 

That's just it - they don't have much motivation to work with us if they know we aren't coming back due to costs.

 

 

2 hours ago, J-rap said:

 

If that doesn't work, I'd go to the insurance company to see if they can step in, but they'll probably be the least helpful.

Good luck!

 

Thanks.  I did speak with the insurance company last night.  The guy I spoke with was very nice and offered to call the dental office on Monday but I don't think there's anything he can do.  He seemed to genuinely feel bad about the situation.  

[scholastica]

1 hour ago, Kassia said:

 

That's just it - they don't have much motivation to work with us if they know we aren't coming back due to costs.

 

 

 

Thanks.  I did speak with the insurance company last night.  The guy I spoke with was very nice and offered to call the dental office on Monday but I don't think there's anything he can do.  He seemed to genuinely feel bad about the situation.  

There probably isn't much they can do. Unfortunately, it's on the consumer to know if the provider is in-network or not. It was so wrong for them to tell you that the dentist you saw was not in-network, when the previous one was and that you were even seeing a new dentist.

[Martha in GA]

18 minutes ago, scholastica said:

There probably isn't much they can do. Unfortunately, it's on the consumer to know if the provider is in-network or not. It was so wrong for them to tell you that the dentist you saw was not in-network, when the previous one was and that you were even seeing a new dentist.

I disagree! The dental office knows what insurance she has and what insurance the dentists take. The front desk at the dentists we have gone to have always explains how much insurance will pay and how much our portion will be before doing a procedure.

[scholastica]

1 minute ago, Martha in GA said:

I disagree! The dental office knows what insurance she has and what insurance the dentists take. The front desk at the dentists we have gone to have always explains how much insurance will pay and how much our portion will be before doing a procedure.

You have gone to dentists who care about their patients and are acting in a professional manner. Not all are like that. My kids pediatric dentist does all that, but we just left a dental office for shady billing practices. They were incompetent at best, intentionally overbilling at the worst. 

Even our pediatrician has a recording in their hold music that talks about how the patient is responsible to know which facilities and labs are covered at what level. It really is on the consumer.

[JFSinIL2.0]

I would call and write a follow up letter to the dentist office noting how long you have been going there, and that no one let you know before the scheduled visit that 1 your dentist had left and 2 they left your insurance network.  Note that you expect them to accept the usual copay, and hope that they are working to rejoin your insurance network.  If they have a Facebook presence, post there, too.

our dentist at one time decided to quit our insurance since he did not like that he was being told by insurance what lab to use etc.. He told us he wanted to make sure we all got the best crowns made, etc.. He had to change his tune and rejoin our network when a great many patients left the practice in search of an in network dentist ( ourselves included).  You might mention to the dentist office that you probably won't be the only family looking for a new dental practice if they don't rejoin your network asap.

Worse case scenario is you tell them you need records transferred to new dentist who is in network, and will make a small payment of (amount you can afford) monthly.  Remind them how unprofessional it was for them to not disclose that dd would be seeing a new, different dentist, much less that insurance was no longer accepted.  And spread the word locally so no one else is taken in!

 

sorry for any typos I hate using the iPad whenever I want to post here

[Kassia]

13 minutes ago, scholastica said:

It really is on the consumer.

 

Yes, it is, unfortunately.  But, in our case, we had no reason to believe that the dentist had changed.  We received no notice and there was no sign at the office announcing the change. 

 

 

3 minutes ago, JFSinIL2.0 said:

I would call and write a follow up letter to the dentist office noting how long you have been going there, and that no one let you know before the scheduled visit that 1 your dentist had left and 2 they left your insurance network.  Note that you expect them to accept the usual copay, and hope that they are working to rejoin your insurance network.  If they have a Facebook presence, post there, too.

our dentist at one time decided to quit our insurance since he did not like that he was being told by insurance what lab to use etc.. He told us he wanted to make sure we all got the best crowns made, etc.. He had to change his tune and rejoin our network when a great many patients left the practice in search of an in network dentist ( ourselves included).  You might mention to the dentist office that you probably won't be the only family looking for a new dental practice if they don't rejoin your network asap.

Worse case scenario is you tell them you need records transferred to new dentist who is in network, and will make a small payment of (amount you can afford) monthly.  Remind them how unprofessional it was for them to not disclose that dd would be seeing a new, different dentist, much less that insurance was no longer accepted.  And spread the word locally so no one else is taken in!

 

Thank you!  I already planned to call on Monday and also to use social media and spread the word locally but I hadn't thought about the letter.  I will also contact the owner of the practice (he works out of another office) if I can't resolve this at our office.  

 

 

[JFSinIL2.0]

saying it is on the consumer to determine if a provider is in network is good advice IF the consumer is looking for a new dentist/doctor etc..  However, an established patient should not be expected to verify before every appointment that their established medical professional ( in this case the dentist at the dental practice) is still in network.  That you were not contacted in advance that there was a new dentist, much less that insurance had changed - on their end - is very wrong.  Fight this. 

If you were in Illinois hubby could help.  Dealing with cr@p like this has been a large part of his law practice for years. 

Edited October 6, 2018 by JFSinIL2.0

[G5052]

Yes, fight it. We ran into this on an ongoing basis with DH. 

Write a letter to the practice manager and follow up with a phone call. Sometimes they will work with you. This happened one time when DH saw a new doctor when his regular one was out of town, and they ended up just charging the normal in-network fee and eating the rest. Apparently he moved up his start date, and they were still in the process of getting all of the insurance connections set up, which is totally the wrong way of doing it from a patient standpoint. Thankfully they agreed.

Then take it up with insurance, although you may or may not get as far with them. Usually there are several levels of appeal.

If all that fails, the office may be willing to negotiate on the bill and/or put you on a payment plan.

Never assume that a bill is final.

Edited October 6, 2018 by G5052

[Lanny]

I would be ANGRY.   I doubt that the insurance carrier can help, but possibly they have some influence, if part of that practice is still in their Network.

Failing that, I would consider sending them $25 USD monthly. Not because I felt their charge was correct, under those circumstances, but because if they report you to the Credit Bureau, it's a blemish. If that happens, I would ask the Credit Bureau to note on my record what happened.

I would be looking for a new Dentist.

I would consider going to Small Claims Court if they caused me problems.

[TechWife]

On 10/6/2018 at 8:10 AM, Martha in GA said:

I disagree! The dental office knows what insurance she has and what insurance the dentists take. The front desk at the dentists we have gone to have always explains how much insurance will pay and how much our portion will be before doing a procedure.

That is done as a courtesy and because it is good business practice, not because it is their legal obligation to do so. They are not legally obligated to do this.

Insurance is a contract between the person who is insured and the insurance company. Providers contract for "in-network" payments, or not. Their contract is between the provider and the insurance company. The contract between the patient and the physician or dentist is that the patient will pay the bills. The patient "assigns benefits" to the provider so that the insurance company can pay the provider directly (this is usually done whether or not the doctor is in-network, however some insurance companies won't pay out of network providers and send the payment to the policy holder instead, it varies). If the physician/dentist is "in-network" they will accept the amount the insurance company allowed for the visit/procedure as long as that amount accurately reflects what their with the insurance company states. They will bill the patient the difference between the amount the insurance allows and the amount the insurance pays to the patient/guarantor (this is the copay). If the provider doesn't have an agreement with the insurance company, they simply accept the payment from the insurance company towards the account and bill the remaining balance (balance between the charge and the amount the insurance company paid). That balance (also known as the copay) is the responsibility of the patient/guarantor.

In my area, the vast majority of dentists do not participate in any in-network agreements because they do not pay enough. Those that do participate are usually store front dentists that come and go like the wind.

[TechWife]

I actually think the larger issue isn't the bill, but that your daughter saw a different provider than the one that she had an appointment with. If she had an appointment with Dr. X and Dr. Y saw her, I wonder if you legally consented to treatment by Dr. Y? If you didn't legally consent, you might be able to use that as leverage. I also would not go to that provider again - I believe that is unethical. You should have been informed that her appointment was changed to Dr. Y and was that okay with you?

Our dentist retired a couple of years ago. He sent us a letter at the beginning of the year stating he would decrease his hours to part time by the end of August and that he would completely retire at the end of December. He also stated that the practice was actively seeking a new dentist to join them and that they would keep us informed. We got a follow up letter some time later introducing the new dentist and stating that he was accepting new patients. We then got one last letter from our dentist shortly before the end of the year, thanking us for allowing him to care for us and stating that he hoped we would remain with the practice. In January, someone from the office called us about our scheduled check ups and asked us if we wanted to see the new dentist, another dentist in the practice or if there was another practice that we would like them to send our records to. Now, I think they went above and beyond in all of this, but this is an example of how to transition between providers when one leaves. Now, my both OB/GYN and my podiatrist also retired and I heard nothing about it until I called for appointments after they had retired. My primary care doc changed practices and I got a letter stating that he had left the practice and that the office was retaining my records. All of that happened within a couple of years - I seem to be the age when my providers retire and trust me, the new ones look really, really young! Any of those scenarios would be preferable to what you experienced.