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Some Common Problems with Dental Offices and Dental Insurances and My Approach

Updated on August 13, 2013

Everybody knows that the idea of seeing a dentist conjures up an open can of worms. Nobody has anything good to say about the experience. The dental chair is equivalent to a hydraulic cylinder car lift, and you are the car that needs repairing. However, nobody knows what the service will cost. There is no consistency. There is a lot of guessing to what is needed, what the service is called, and therefore what code starting with the letter "D" will be used. Insurance companies haggle with you regarding the code, trying to find one that does not cover your needed procedure.

The Typical Situation

The way the dental business works is that it will contract with a health insurance and agree to provide certain services for a basic co-pay such as $5 because it is receiving a certain amount directly from the health services. This is known as capitation. Whether you visit the dental office or not, the business makes money. So, for those who do not want to go regularly, the dental office is happy about it. Typically, you receive two free cleanings by a dental hygienist and one x-ray reviewed by the dentist. If you have more plaque, you are asked to go an extra one or two visits per year. A friend of mine is the son of a dentist, and he said that ideally, a patient should go 6 times per year for the best care. After so many years, the dental office will recommend a deep cleaning. If you have pockets because of some teeth that were pulled, then they may be infected, and you might need some antibiotic treatments. You might crack a tooth here or there.

The Problems

If all you need are the two regular cleanings and the annual extra, there would be no problem whatsoever. However, the problem begins when you need anything else done to your teeth. The dental office charges different price depending on your insurance company, just like you will notice that different patients have varying co-pays. Unlike a medical visit with a mere co-pay, a dental patient is now looking at procedures that can cost many thousands of dollars. They assume that you will receive some discount, but their main concern is that the office has you to agree to seek the procedure. It makes no different whether you pay them or the claim is put through the insurance. So, with all of the different insurances, what is the price that you pay? Let's say that the dental office thinks that insurance will cover it and that your portion is $405. You then go through with the procedure, and the office is telling you that the insurance concluded that the actual cost is really $608. How can any patient feel comfortable about the financing of dental work? WIth a car mechanic, no garage is going to come back and say that the cost that it quoted you was an error and that the real cost is something much higher. Then, you take this one problem and exponentiate it with deep cleaning, bridge work, antibiotic treatment, anti-cavity treatment, etc.

I wanted to determine whether supplemental insurance is worth carrying, once we complete the 2 year service and once my children have their orthodontia work done. I also was determine to end all of this craziness. So, I spent 2.5 hours and spoke to 6 representatives. And I discovered that there were even more problems. Another problem is that a dental office may not have filed a claim with your insurance. The question I often wonder is whether the office would find the need to bill me for the entire amount in the future. This problem could snowball. However, what I did not expect to hear from the insurance company was that a number of the procedures could have been covered had the office supplied some narratives and explanations from the dentist that the procedures were necessary.

The Solutions

1. Don't Be Left In The Dark. Don't agree to the procedure right away unless it is a dire emergency. What you need to do is ask for the specific code. Oftentimes, the dentist will tell you that you need it, but most procedures do not have to be done with the same visit. You can wait a day or two. However, before you leave the dental office, ask them for the specific code that is needed, and call your insurance company to see how much it will actually cost you versus what the dental office says is the actual cost.

2. Ask For A Year's Invoice To Review. A dental office should be able to print a year's worth of invoice for you to review. You have to be proactive to see whether the office has submitted the claims to your health insurance and your supplemental dental insurance. You need to check whether it was submitted to both, if you have both, because the office administrator can make mistakes.

3. Ask The Insurance Company For Research. I did not realize that you can bring all of your problems to the insurance company. Over the phone, ask the insurance representative whether a charge is legitimate or should it be something included with your preventive care. For example, should the antibiotic treatment be covered with a regular cleaning? Should the anti-cavity treatment be included in a child's visit?

4. Ask the Insurance Company To Contact The Dental Office. I learned that you can ask the insurance company to instruct the dental office to do certain things, such as refund or credit an adjustment to a payment. I learned that the insurance company cannot forbid a dental office from collecting payment for service on the same day. However, some dental offices may not be good at crediting you the different when the claims have eventually been paid by insurance company. The insurance company will also remind the office to supply narratives so that it can complete its research and determine whether it can cover additional costs.

5. Remind the Office To Review Past Charges. If you know that you can pay less for a procedure that you have had already, then do not forget to ask the dental office for a full audit of past payments. For example, I learned that irrigation was not $36 but $24. Then, you should be credited for the difference for all of the past services.

6. Ask for the Invoice Shortly After Each Visit. Be proactive when you have reviewed all of your past procedures. Call the insurance company right away and review the code, ask whether all claims have been filed, and if not call the dental office to remind them to file the claim promptly. Only when I told the dental office that I was working with the insurance company did I learn that my spouse's deep cleaning in March 2011 was not processed until December 29, 2011. Some insurance companies have deadlines for filing claims.

7. Keep All of Your Dental Invoices Together. You want to be in control of your dental situation by knowing exacting the what code is needed for what procedure. Of course, there will be times when you need a new dental procedure, and then you can refer to #1.


Dental procedures are costly. Some people are lucky enough to have minimum dental benefits with their health insurance, and others even purchase supplemental dental insurance. I have been frustrated with the financial problems that arise whenever my family and I needed additional dental work. I hope that the solutions that I found can be beneficial to others as well.

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    • formosangirl profile image

      formosangirl 5 years ago from Los Angeles

      I appreciate your personal experience in the industry. However, every insurance is different, and every dental office is different. The entire dental claim process is totally different from regular medical practice. I am not the only one who complained about how my dental office's process works. I would really like to have an administrator such as yourself at my dental office. Thanks for leaving me your feedback.

      In fact, not once has my administrator sent an x-ray to have my supplemental insurance cover the two additional cleanings per year. In our household, that's four extra cleanings per year, and that adds up.

    • profile image

      Morgan 5 years ago

      I find this advice very flawed. I have worked in a dental office for 10 years. My job is nothing but filing and appealing claims. I will spend all day verifying a new patients benefits or getting authorizations on procedures codes just to have something denied when the claim is sent. Patients have no idea how much time I put in appealing their denied claims by sending narratives and X-rays and sending more narratives. Insurance clearly states nothing is a guarantee. Even pre-authorization. The dental office does not determine your eligibility or benefits nor can that diagnosis you and tell you what is needed without being inside your mouth. As a participating provider of many plans we can not charge you by law anything over your insurances contracted amount. And I have never come across an insurance company that includes arresting anitobotic with a regular cleaning. Everything is subject to review. Trust me, I am constantly made out to look like the bad guy. Insurance will tell the patient one thing and myself another. I also have never heard 6 cleanings a year? Maybe 4 if they are severe perio. It's good you have done your homework but it sounds like you have out way too must trust into what your insurance company has told you. There are a lot of dentists out there, like every other doctor, that will work the system but We are not all like that. Dental is very expensive and precise. Dental insurance is in no way the same as medical. In the end it is your insurance and if problems are arising you should probably file it yourself.

    • formosangirl profile image

      formosangirl 6 years ago from Los Angeles

      Thanks, Teaches12345. I am hoping that more dental patients will be knowledgeable consumers in this world of obscurity.

    • teaches12345 profile image

      Dianna Mendez 6 years ago

      Thanks for writing this hub on dental offices and procedures. I often wonder what the treatment costs are and how they are billed. Good advise and will certainly follow through on a few next time I at the office. Voted up!

    • formosangirl profile image

      formosangirl 6 years ago from Los Angeles

      Alocsin, thanks for your feedback. In my neighborhood, it is hard to find a dental office that did not have columns or marbles somewhere. I practically receive "deep cleaning" with my quarterly visits but she needed to go deeper every so many years. This office is not cheap. And we like the fact that they do not hound us on flossing. Dental visits are difficult to begin with. No guilt trips please.

    • alocsin profile image

      alocsin 6 years ago from Orange County, CA

      I'd like to add to pick a quality dental office -- they may charge more but in the end they'll save you money. I used to have a terrible dental office -- they were cheap but their work would fall apart every few years. Now that my dentist is better, it's done once without any problems. Voted Up and Useful.