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Can a dentist in-network charge above and beyond the contracted rates?

I have Delta-dental. My plan covers 2 free exams and x-rays per year, with a $50 yearly deductible and 80% coverage after that. My husband went to the dentist and had a blemish in his enamel which was filled. It was NOT a cavity. We paid the $50 deductible plus $15 for the 20% and now he's trying to bill and additional $34 after the insurance paid their share. I have since quit going to this dentist because of this and other reasons- fillings (after insurance) cost $100. It seems to me he's over-charging. Is he legally able to do this? How about ethically? If not- what's my recourse or do I need to just cut my losses and find a more ethical dentist?

Public Comments

1. call the insurance company - they should be able to get him off your back. good luck.
2. Deltal participating dentists can not charge anything over what he is contracted with. If he does, that is an insurance fraud and unethical. If you feel that he has over charged you, take up with his office. If you are not satisfied with him, call or write to Delta. Delta dental will investigate and determine if there was any insurance fraud. There are time when a certain procedure is not a coverage such as veneers, but Delta has set a fee with the dentist and he is obligated to collect only that amount. If he collects more than the set amount, he is breaking his contract. Hope this helped.
3. if the dentist does not get the money from the insurance, he will get it from you. this is sad but true. most will give you sub- standard care if there is a question of not getting what they think is their fair share. i have spent more money than i care to think about and i still can not chew my food. yes i had insurance. i found out my dentist uses one lab for my insurance and another for people willing to pay the full difference between the insurance and his costs. doctors do about the same thing. if it does not cause to much harm tests are not run if the insurance does not pay enough . if you have a good dentist pay the money and get the work done right. good luck
4. An in network Dentist must accept what Delta pays him and should not bill you.Call Delta and tell them what happened. Don't pay him. I had the same problem with an in network Doctor and reported him to the insurance company.The insurance company wrote to him and said to stop billing me.
5. What the additional fee may be a result of is downgrading. Some insurance companies don't cover tooth colored fillings. Instead, they will downgrade their payment to 80% of the cost of a metal (amalgam) filling. A patient can get billed for this amount. This has nothing to do with your dentist not be ethical or doing something illegal. As far as I know, a dentist doesn't have to write off the difference if the insurance decides to downgrade the procedure. Many insurance companies will only pay for the cheapest restorative procedure that can be done to repair a tooth. This can happen with fillings or with a crown. This is one reason that most insurance companies won't pay for dental implants. Even if an implant is the best option for replacing a tooth, it is not the cheapest restorative procedure. Many insurances will instead pay towards the patient getting a bridge or a removable partial, since these would be cheaper. If your dentist doesn't do amalgam fillings in his office, you are probably always going to have to pay the difference between the cost of a tooth colored filling and an amalgam one. It would probably be the same if you changed dentists and went to another one who did only tooth colored fillings. In order to not have to pay this difference, you would have to find a dentist who does amalgam.