Should I be made to pay fees I was led to believe were to be paid by Delta Dental?

Question

I chose to upgrade to a "Special" dental plan of Delta from the "Standard" dental plan, both of which I have through my employer. Before upgrading, I researched how much of a crown the Special plan would cover. According to the info sheet my HR department gave me, 90% was to be covered for a crown provided by a PPO Network Dentist, and if it was a Non-PPO Network Dentist, Delta would cover only 60%. I asked the dentist if they were a member of Delta, and they said yes. (Since they had not been able to give me an idea of how much the crown would cost me, I made the effort to do this research) I then told the dental office it was 90%. But it turns out Delta only covered 60%. I only learned after that there are different kinds of Delta members (my dentist was member, but not a member of "Delta Premiere"). If a provider is a member of Delta, don't most people understand it to mean they are therefore part of the PPO network? Very misleading. Who can I show is responsible for these fees?

Answer 1

I'm sorry that happened to you. However, you are still ultimately responsible for the charges. Just because a dentist's office accepts an insurance, doesn't mean they are in their network or extended network. The insurance company will tell you that you had the responsibility to obtain a list of PPO dentists and choose from that.

Ask your dentist's office if you can make a payment agreement for the charges. Or see if he or she is willing to come down a little in the amout owed.

You can also try appealing the insurance decision, but don't be surprised if the 60% is upheld.

Answer 2

You are responsible since you should have made sure that this dentist was a provider of your "upgraded" insurance. This dentist office could have sent in a pre-determination and given you the exact amount you would have been required to pay out of pocket. Next time have them do that (most offices do that in advance anyway) instead of guessing or assuming. I can understand what you are going through, I had to leave my personal physician of many years when I changed my plan by upgrading. A new plan can be misleading and very difficult to understand, but you are paying for better insurance coverage. Some dentist just can't afford to take every plan based on what the insurance companies are willing to pay. Sorry this happened to you, but you aren't the first and won't be the last. I wish I could be of more help, good luck with future dental visits and be sure to get a pre-determination first.

Answer 3

When someone calls and asks if we 'take Delta', we tell them that we are a participating provider, BUT, depending on which plan they have, they may have out-of-pocket expenses for their dental treatment.

You are responsible for the outstanding balance that Delta did not cover. You can ask for a copy of the EOB (explanation of benefits) that accompanied the benefit check.. if it there's a fee listed under 'patient's responsibility', then it is what it is... but if it says $0, then they are attempting to scam you and it's insurance fraud.

I agree that a pre-treatment estimate should have been submitted to get an idea of what your out-of-pocket expenses were going to be, if any.

But for peace of mind, request to see a copy of the EOB. There must be other people that have the same insurance that you do.. why not ask them where they go?

~Just a thought.

Answer 4

you are. you just didn't investigate quite good enough.