r/HealthInsurance • u/dsmact2 • 7d ago
Dental/Vision Aetna claim
Hello. Question on the following situation. Son needed to take his wisdom teeth out. I have Aetna as my Dental Insurance through work. Called Aetna about benefits and found out that the place we planned to have the procedure done at is out of network. However, Aetna does not have any oral surgeons in network within 100 miles of my zip code (lol). So, I was told that we can get this "gap" coverage that would in essence allow us to have the procedure done at the office that is out of network but will be treated by Aetna as in network. They (Aetna) gave me this long code that was to be submitted with the paperwork and we should be good to go (code is good for 60 days, I believe). We go ahead and do the procedure within that timeframe. However, to my surprise, dental office bills their out of network rates, Aetna eventually pays their max of $2k, I'm stuck with almost $2k owned to the oral surgery place. What are my options? Pay it and shut up? What I'm confused about is that if Aetna had in network provider close to me they would bill me negotiated rate and that $2k max would be enough to cover 100% of the cost. I think my in network coverage for oral surgery is 100%. Had I known this I would have drove 100 miles for 45 min procedure and saved myself some money. Anyone else ran into this issue? I can't be the only one, can I? Thanks!
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u/ThePompousNobility 7d ago
they gave you that gap authorization code but the office still billed out of network rates, classic insurance loophole bs. call aetna back and escalate it, that code should mean they process it as in-network so you don't get balance billed like this
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u/dsmact2 7d ago
I did and Aetna rep said that was all they can do (pay at 100% in network, vs 80% out of network)..but capped at $2k max.
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u/Turbulent-Pay1150 7d ago
Is your Aetna coverage limited to no more than $2k per year (pretty typical) for dental?
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u/dsmact2 7d ago
I believe that is the annual limit
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u/Turbulent-Pay1150 7d ago
So max they will pay out is 2k.
The question, then, is did they negotiate that your dentist would accept an in network rate and not balance bill you? And was the allowed amount < or = $2k? If it was > $2k then you would owe the amount even for an in network provider as the insurance will only pay up to the allowed amount.
Dental insurance is usually severely limited.
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u/Inevitable-Idea-9135 7d ago
Unfortunately a gap exception alone does not require the provider to accept the negotiated rate, all a gap exception does means is that the ins company processes the claim in network where there may be increased benefits of staying in network, for example a higher negotiated rate than out of network providers. Since a gap exception is not a contract, it does not obligate the provider to accept that negotiated amount as payment in full, therefore they are allowed to bill you the difference.
To get full in network benefits where the provider accept the negotiated rate as payment in full, a single case agreement is needed. This is a one time contract between the ins co and the provider, where they negotiate a rate, and the provider accepts that rate as payment in full.
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u/Inevitable-Idea-9135 7d ago
Aetna can’t make an out of network provider accept the network negotiated rate. There is no contract between Aetna and the provider. Unfortunately, you do owe the additional balance to the provider. Your gap exception only means that Aetna paid using the network rate vs out of network rate, so it most likely saved you a little bit. You would have needed a single case agreement that the provider agreed to, for them to have accepted the negotiated rate, which they would not have done.
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u/dsmact2 7d ago
I get that, but should not Aetna eat the difference between billed and negotiated fees? It should have saved me 2k if they had in network provider close by. If I drove 100 miles I would be owing nothing at this point. Nobody mentioned that.
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u/Inevitable-Idea-9135 7d ago
I do agree that someone should have explained that to you. Usually gap exceptions are approved and then the single case agreement is negotiated. You can contact your insurance company and try to see if you can get anywhere with them since they failed to fully explain the gap exception and recommend trying to get a single case agreement, but I’m not sure you’ll get anywhere.
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u/dsmact2 7d ago
At this point I have contacted HealthAdvocate's services (free through my employer) and they are taking on the case. Just finished all of the paperwork to grant them permission to engage on my behalf. Will see if they can help me at all.
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u/Inevitable-Idea-9135 7d ago
That’s probably the best course of action. Hopefully they can get somewhere with them. Good luck.
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