Scan Medical Insurance

Dentists, medical billers, insurance people...help!!?

We have Aetna DMO and I just had 3 crowns done by my PCD. They told me my co pay would be $750 per crown!! That's how much I used to pay before I had insurance. I asked her if she was sure and she said yes. I went ahead and had the work done and left paying the $2250. 4 months later my teeth are still hurting so I went to another dentist and they told me my co-pay should have been $305 NOT $750!!! So I called Aetna and they said I have to bring it up with the dentist office. When I went in there I asked to see the contracted price sheet for aetna and she claimed there wasn't one. So how do they calculate my co-pay if they don't have that information? Do they owe me a refund?? Both Aetna and my new dentist told me I was overcharged. What do I do if the dentist won't refund my money or what info can I bring with me to show they overcharged me?? YES this Dr was my primary care dentist assigned to be BY my insurance company so she was definitely in network. When I asked the office for a price sheet, they said they didn't have one...they just go by the DMO list?? Don't they have to go by what Aetna tells them? They claimed that my copay was $750 when it was actually $305.

Public Comments

1. Are you certain that your dentist was in network for the DMO? If he wasn't contracted with the insurance company, then the fees would have been his regular price instead of discounted. You can bring something to the old dentist that shows his fees are above reasonable and customary (you'll find that more dentists are - the insurance companies are pretty slow in staying updated with the rising cost of living) and ask him to split part of the difference with you. The office I work in is not contracted with any dental plans. We offer this information up front so the patient is not suprised later. Whenever there is any dispute, the insurance company always blames our fees verses what they are willing to pay. The lower price does sound more like a DMO co-pay, double-check that you were in network - that's the only leverage you'll have with the dentist regarding the high fees. Good luck.
2. The most importatant thing would be to make 100% sure that this dentist was a contracted provider for this insurance. My office is out-of-network for all insurances, and when a patient calls us they always ask "Do you take my insurance?" Our answer is usually "We can file on your insurance but we aren't contracted with them." These patients come into the office for their exam and xrays and want to know why they have a copay. They also want to know why the insurance company isn't paying 80% of fillings or 50% of a crown. We then remind them that we aren't a contracted provider, and 95% of them say that they don't know what a contracted provider is. If a dentist is a contracted provider, they can only charge you the amount that the insurance company sets. For PPO's that is called UCR. For HMO or DMO it is usually called their "Fee schedule". You need to #1 find out if this dentist is a contracted provider. If he isn't, he can charge you whatever price he sets. If he is then you need to get a copy of the Aetna fee schedule. Since my office isn't contracted, I don't have one to help you out. You should be able to get this from the insurance. If it turns out that they are contracted with Aetna, and you get the fee schedule, you should be able to use that to show them that they overcharged you. This just sounds strange, because if they are a contracted provider, they know already what the contracted fee schedule is.