I was originally told by the dentist that my insurance was going to cover 50% of the NTI, but I wasn't informed that the insurance wouldn't cover any of the expense until after I was given the impression for the NTI. I should have been told days prior to my appointment that the insurance wasn't going to cover that expense. At the very least, I should have been told first thing on the day of my appointment -- prior to getting the impression for the NTI. If I knew that I would have to pay 100% of the expense for the NTI, I wouldn't have done it.
I paid the dentist the full amount ($689) via credit-card. I asked for the receipt and the dentist gave me the receipt with the procedure code D9870 with the service description of TMJ Guard. After my appointment, I contacted Delta Dental and found out that they do in fact cover the TMJ Guard. I filed the claim. However, the code that the dentist gave me which was D9870 was not recognized by Delta Dental. Delta Dental told me to go back to the dentist and asked for the right code.
I went back to the dentist and they did provide me with the new code D9940. I submitted the claim again with the new procedure number code (D9940), but this time it was rejected because the billing provider's tax identification number (TIN) was different from the one that Delta Dental has on file for the provider and office location.
I called my Delta Dental again, and the Delta Dental agent -- showing proper "customer support" -- helped me submit the claim with the correct TIN information.
Delta Dental processed the claim and sent the check $224 to the dentist. I got the explaination of the benefit with this information:
Amount Submitted was: $698.00
Delta Dental's amount approved was: $280.00
Delta Dental's CO-Pay percentage is: 80%
Patient Payment is: $56.00
Delta Dental's Payment is: $224.00
I was told that the total patient payment from me should only be $56.00. I called the dentist and asked for the refund. The office manager said I will get only $224 that they got from the insurance. I tried to explain to her that I should get $642 ($698-$56) back. She still insists that I can get only $224.
She said the code that Delta Dental eventually made payment for was not the procedure code for the NTI that was made for me. The code Delta Dental paid for is for a different type of niteguard (not an NTI) which is far less superior than the one that I have. However, in my research I found that in general the same insurance codes for splints, TMJ appliances, habit appliances all apply to the NTI-tss Plus™.
Code = D9940 occlusal guard.
Bottom line, they won't give me back my money. I called Delta Dental and they told me to send a grievance report to them. They will try to get the money back for me. What else should I do? My family told me to write the letter to the Attorney General and also the Better Business Bureau. They falsely represent from the beginning by telling me that the insurance will cover 50%.
HI----I wish that was my scenario...My old dentist owes me about 6200.00 dollars for failed tmj treatment, and I reported him to the State Dept. of Professional Regulations, and I got absolutely no where...I might still file a lawsuit against him, but due to the added stress and nightmare of the whole thing, I don't know if I will. It is extremely hard to recoup funds back from dentists. What they are doing to people should be illegal, and should be seen as malpractice from the dental community. It's outrageous. Like I always say, there's a front row seat in hell for every Tmj specialist who takes us for a ride, and then blames the patient for non-compliancy or some other dumb reason for the treatment failing.
It sounds like the insurance company is on your side. I would work with them and follow their procedures as far as it goes, step by step. Try to set aside your emotions as you jump through whatever hoops are required. Document everything, including phone calls (date, time, who you talked to, a summary of what was said - it doesn't have to be word for word). Keep copies of everything. When all is said and done and if there is still no satisfaction you may simply want to file a small claims lawsuit against them. You can do it yourself and the fees will added to the judgement. Send a demand letter first. Chances are the dentist will just pay you rather than go to trial. Be sure that your settlement agreement includes the court costs you. Inform him that if does not pay prior to filing, he will have to pay those fees to avoid going to court. Of course, you'll never be a patient in his office ever again but that was probably already true!
jmitchell - Sorry to hear about your story. That is a big amount.
esker - Thank you so much for your advice.
I tried to contact back to the dentist via email many times. The office manager still insisted that I will get only $224 back. In my last email, I told them that I will report this to the Attorney General and Better Business Bureau. Now they said they will give me full refund but I have to give them back the NTI.
What should I do? I still need a night guard. I am afraid that if I go to the new dentist, I won't be able to get it because I already got it before from this dentist. The insurance won't know that I return them and the insurance will have the record that I have the NTI before.
Esker, I don't understand why I have to give the dentist another $224. The dentist already got the $224 check from the insurance. I paid $698 and I never got any money back from the dentist.
The dentist got money total of $922 ($698 from me and $224 from the insurance). I just want the money that they overcharged me which is $642 ($698 - $56).
I don't think I can negotiate. The dentist instructed me to give back my NTI for full refund, no exceptions. They are not willing to give me the money they overcharged me.
I already filed the report with the insurance. I want to make sure that if I really have to return my NTI for full refund, the dentist have to return $224 to the insurance. I am afraid that the dentist will keep $224 and now I cannot go to a new dentist to get a new NTI because the insurance has the record that I already have it.
I learnt my lesson. Next time I will have everything in writing.
If I was you I would be fighting tooth and nail. The dentist OWES you that money. What the insurance company says- GOES!
They have to comply...what you need to do now is file a grievance with the insurance company and let the dentist's office know exactly what you are doing. I'm sorry you are out of the money now, sometimes we put too much trust in how situations are going to work out problem-free.
Good luck to you. Unfortunately, this will put a strain on the relationship you have with this office and future dealings.
ON a good note I would like to say that there are awesome specialists out there. My mouthguard was not covered by my insurance. They tried to help me out by getting a credit card (which we already had one with the same co. ironically), or pay 1/2 now 1/2 later.We just flat out did not have the money. My doctor's office called me and asked if I would like to be part of a "pay it forward" program where all I have to do is come up with 1/2 of the money and the rest I can work out as a volunteer at a local pregnancy center (@ $100 an hour) to go towards my expenses. basically a plan of $2900 , 14.5 hours at a shelter, and $1450 for the mouthguard. What is the saddest of it all is I don't even have $1450. But how cool is that to even be offered?
Madmas---that is awesome that your dentist would even consider a payment plan like that. I've never heard of anything remotely close to that. As far as trying to collect on tmj treatments that don't work...good luck. LIke I said, I went as far as emailing my dentist, calling, filing a complaint with the Dept. of Professional Regulations, and I still got absolutely no where! My old dentist even made sexual innuendos towards me, and they knew about them, but yet did absolutely nothing..It's bad enough that they owe me almost 7K, but the fact that the board just lets these dentists operate like this without even a slap on the wrist is unimaginable to me. I haven't pursued a lawsuit against him, but I'm keeping that open at this time. I figured though, if I can't get anywhere with the Dept. of Reg., how in the heck can I win a lawsuit against him? so frustrating...
I am sorry about your experience but let me educate you a bit about insurances. Other people have stated what the insurance says goes, it a false statement. First, you have to understand that the dentist has no relationship with the insurance, "you " have a relationship with your insurance. not the dentist, the dentist has it with you. the fact that you have to file your own claim, means that your dentist is a FFS, fee for service provider. That means, your dentist charges about $650 dollars for your appliance. The fact that you had to pay out of pocket means, they had no responsibility wether your insurance paid or not. Because you have dental insurance, they would reimburse you up to a certain amount, unfortunately for pts, insurance companies do not use "real amounts" they just make up specific amount, let's say $450 dollars, and they use that amount to calculate the % they pay. Let's say $ 224. This does not mean that the dentist will take $224. He was very specific when he asked you for over $600. I understand your disatisfaction. Very often we assume that when insurances say they cover 50 percent it will be true. They often fix everything by "file a grievance". When you file the claim, you should have checked a box, saying money goes to patient, in this case it went to the provider. I am affraid that is all you are entittled to. That is the amount your insurance will reimburse. If you are threatening the doctor with filing all these claims against him, he will probably give you the money back, just cause he does not want his reputation to be affected by $500. it is not worth it to most professionals. Anyone with dental background will know, that this is a case of misunderstanding what's a covered expense and what is not.
I hope you resolve your situation, but if you are satisfied with the work, I suggest you both give in and perhaps go half way. $450-500. due to the true misunderstanding. That will still be fair and it would be the amount that your insurance will consider the maximum fee. THe dentist then does not lose money and you get a discount. $224 from your insurance and 225 out of pocket, they can refund you the insurance money+ another $200 or so.
If not you will have to get the money back, the appliance, get a refund and then go through dental work with another provider, which means insurance pays around $200 and you pay the rest. I hope this helps you understand how dental insurances work.
Better luck next time!!!!!
I haven't had private dental ins for a couple years now so things may have changed since then, but it used to be a dental plan was designed with an in-network and out-of network reimbursement claim processing protocols.
In-network meant that the dentist had an agreemnt with the insurance co to only charge and accept as assigned payment what the ins co established as the approved amt for specific treatment.
Out-of-network meant that the dentist did not have an agreement with the ins co - the plan however would allow patients to be reimbursed for certain treatments but at a slightly reduced approved amount that they would establish - less the patient copay. The percentage of reimbursement was usually less as well. Since the dentist did not particpate or accept assignement of the insurance co however they could charge the going rate or what the market in their area dictated (what other dentists charged) and rightfully expect to be paid accordingly as the issue of reimbursement is between the patient and the ins co when a dentist does not accept any insurance.
I would find out if this dentist was a participant of the dental plan you have or not - if he said he was and then it turns out he wasn't, then that is misleading and you could file a complaint against him. If the claim was paid based on out-of-network rates you then know he does not particpate in the plan - the claim paperwork should say how the claim was paid - in or out of network. The fact there was an issue with the ins co determining the correct TIN also suggests he was not part of the plan and this claim was processed as an out-of-network claim. The other issue from what I could gather is that the claims processor you spoke with submitted this claim on your behalf - so they changed the diagnosis code that the dentist initially provided on a statement and per the dentists office this changed the amt the claim was approved for and they also submitted the claim as if the dr was due the reimbursement, not you - a mistake on their part.
As it stands right now you are only entitled to be reimbursed by the dentist for whatever he received from the insurance co - the amt should have been sent to you but was sent to the dentist in error. The issue of whether he mislead you by saying the NTI was FULLY covered by your specific insurance company implying that he charged and accepted assignement of their approved amt ; and the correct diagnosis code that should have been used, however, could change this.