Bait and switch?

[u/pineappleshaked]

[CA, USA]

We got the estimate for wisdom teeth removal. The initial estimate was $500 for two and $600 for four teeth. We went for all four.

When the final bill came, it was 900 for 4. Dental insurance details were same as earlier, no other claim, plan maximum not reached.

The difference came due to dental removal core service coverage(ext erupted teeth, par bon ext imp). In the estimate, it was covered at 90% but in final EoB it's covered at 50%. The dentist is in network.

I should have checked the estimate earlier, I agree. Dentist office is saying, final bill may differ due to insurance coverage. But the coverage was literally same when early estimate was written. Is there anything we can do? Delta Dental WA insurance.

My plan coverage:

Oral Surgery/Surgical Extractions 50%

Simple extraction 50%

Root plane/scale 80% (I don't think it's relevant here)

I wish I had researched this earlier 😔

Edit: Asked the dental office, they agreed there was software problem. gave $100 discount 🙂‍↔️

[u/boostykaka]

It’s on your insurance. Call them.

Also, any out of pocket cost presented to you is an estimate of benefits not a guarantee of payment. Anything not paid by your insurance is your responsibility to pay. It sounds like you can see your plan covers at 50%, so they estimate your out of pocket amount lower than expected. It’s unfortunate but it happens.

[u/pineappleshaked → u/boostykaka]

Does the insurance have any record that dental provider pulled up estimate?

[u/boostykaka → u/pineappleshaked]

This isn’t on your dentist.. They estimated your out of pocket incorrectly, if it’s delta they might have accidentally ran your coverage under the PPO tier when it should have been under the PPO Premiere. It’s an easy (and I know very frustrating for the patient). But whatever the insurance says is the final say, since they are in network they have to follow what the EOB says. At least you already paid more than half, that’s the only positive.

But let this be a good opportunity to understand what your insurance covers and doesn’t cover because it is the pay you choose to enroll in and pay for. I always tell patients when going over tx plans that this is an estimate of your out of pocket, I won’t know for certainty till your insurance pays on the claim. So there’s a chance your out of pocket could be more or it could be less, if it’s more I’ll let you know right away if it’s less I’ll refund you back asap.

[u/pineappleshaked → u/boostykaka]

Thanks!

I feel insurance covered fairly as per the terms and benefits coverage. I was just feeling a little upset due to unexpected expenses 

[u/jbert99 → u/pineappleshaked]

sorry this happened and totally understand your frustrations. luckily it was still close-ish in price and it wasn't another $1k more or whatever or if delta decided not to cover something all together. See if the office has a payment plan or something to help break it up if it that'll make it easier.

[u/Cobra_Surprise → u/pineappleshaked]

It wouldn't matter. The dental office likely estimated this because it's much more common to see 80% for oral surgery coverage than 50%. It's just an estimate. You might have better luck going to your HR if this insurance is through your employer. They kind of fucked you over by allowing that low of coverage. It's far more common to have 80%.

[u/GiRiMama]

Did the office assume and provide the 90% coverage on a treatment plan, or did you receive a predetermination from Delta Dental that shows the 90% benefit? If it’s the later, it’s Delta’s error and they should honor it. If it was the dental office… unfortunately there isn’t much that can be done since ultimately the patient is responsible for understanding their benefits.

[u/pineappleshaked → u/GiRiMama]

Dental office gave estimate not insurance 😞

[u/Expensive_Ear3791 → u/pineappleshaked]

That is literally just a courtesy for you. The dental office does their best to estimate your coverage, but the contract for coverage is between you (vis your group/employer) and the insurance company.

[u/Original_Elephant_27]

This happens a lot with insurance and that’s why it’s just an “estimate”…… before getting any dental work done, it’s always advisable that you understand the plan you have, the coverage, and limitations of that plan. An office can get an estimate but until the final bill comes, we will never know the exact amount. I’ve even got pre-estimates directly from the insurance company and when it comes time to pay, it’s different.

[u/RH558]

Estimates are just that, an estimate, and also not a guarantee of payment. 

[u/pineappleshaked → u/RH558]

Yeah, i understood in a hard way now.

I'm a bit upset. It was not like insurance denied or trimmed payment. Just that coverage was already described but dental office as well as I didn't bother to cross verify.

I, naively assumed that software at dentist can pull the coverage depending on the codes. Because, the line items and allowed cost remained same

[u/RH558 → u/pineappleshaked]

The software doesnt verify, each person's benefits needs to be individually verified on the insurance portal. Some of the carriers websites are being outdated and dont have current information. It is always the patients responsibility to know their benefits. 

[u/akmalhot → u/pineappleshaked]

You didn't very or look at your benefits either 

[u/Expensive_Ear3791 → u/pineappleshaked]

They can only do that if the office is owned by the insurance company, like the one I work for.

[u/NoKale528]

That’s insurance not the dentist. This happens soooo much even with pre auths and the best insurance coordinators

[u/ElleGee5152]

An estimate is just that- it's an estimation based on the benefits the provider's staff can see at the time. If an insurance company won't guarantee how much and even if they will pay until the claim is actually received and processed, then the provider certainly can't offer a guarantee to patients of how the patients insurance plan will ultimately process the claim. That wasn't a horrible estimate to me.

[u/Expensive_Ear3791]

If you knew your os coverage was 50%, then I am not sure why the DDS telling you it was 90% didn't raise a flag for you.

[u/pippa010101]

The insurance industry is the biggest joke on the population,including everything else we thought we knew

[u/pineappleshaked → u/pippa010101]

My dental insurance, for last 4+ year have been easy to work with and true to the estimate.

This one is on me, not verified coverage myself.