My question involves dental insurance coverage and pre-authorization.?

For example. Say I have coverage through my employer. I go to a dentist for a root canal and ask whether or not my insurance is accepted. I am then told that it is accepted. The work is performed and later I receive a bill for services. I contact the dentist who says there was a problem with your insurance. So I guess my question is, what obligation does the provider have to verify coverage? Is there any recourse after one has relied on a representation that a cetain procedure was covered and it is later discovered that it was not?

My question involves dental insurance coverage and pre-authorization.?
Unfortunately it is always the responsibility of the patient to be aware of their dental coverage. It should be outlined in the patient's handbook. The provider only has contracting discounts that the are obligated to take. But if a service is not covered there is not obligation to the provider. Even when a service is pre authorized it states that it is only an estimate and is never a guaranty of coverage. Remember there is a difference between "accepting" and insurance plan and coverage verification. Individual services are usually covered at a percent that is set by the employer. A patient is still liable for a difference in the insurance's usual and customary fee and the provider's fee, plus any deductible remaining, in addition to that percent set by the employer. It is possible for a patient to be liable between 30 - 50% of the actual cost of a root canal with an accepted insurance.


I manage an endodontic practice, here I always tell them that we accept most insurances though we are only in network and contracted with a few. Even though we accept most insurances this only mean we will accept any payment they make. But say the insurance doesn't respond, We bill the patient. We also state the we only file claims to insurances as a courtesy but again we are not obligated to.


I hope this info helps.
Reply:Do you have documentation that he was an accepted provider and that the root canal is to be covered under your plan (some don't cover it)
Reply:My first instinct is to say, "the provider has zero responsibility to verify or explain YOUR insurance policy to you" since the office only accepts and bills your plan as a courtesy.





But, the reality is, dental offices should have at least some idea about your insurance and whether or not they are a member of the plan's network. Mostly, they will tell you what your coverage ESTIMATE is, which is certainly not a guarantee.





Here is what you should keep in mind, however - if the front desk person calls your insurance company, they might be told "Mr. Jones is covered as of the last report from the employer. His coverage is valid through February." Later, it turns out your employer didn't pay the premium for March and the coverage is cancelled. How would the dental office know this?





Or...you go to another office and have lots of work done. Your maximum is used up and dentist B knows nothing about it.





Or...you had a cleaning 3 months ago at another office and the insurance denies a second cleaning due to a frequency restriction.





Or...your employer has a 12 month waiting period on major work. Yes, you are covered but not for root canals.





Bottom line is, YOU should know what your coverage is, which dentists you are allowed to see, and what the restrictions and clauses are. Your employer provides it for YOU and it's not up to the dental office to know every detail. Take the responsibility for knowing your own benefits, and if money is an issue you can always call yourself.
Reply:It is your responsibility to know your insurance policy. There are hundreds of policies out there and you can't expect the dental office to know yours. If you have any question on what your insurance will and will not pay for, call them yourself.
Reply:I worked with insurance for 3 years. It is 100% your responsibility to know your own insurance. It is a courtesy for the offices to verify your benefits. They can speak to anyone in the insurance department and might have been given wrong information. Advice for future, do your research before you do anything that involves insurance.
Reply:I can help you save additional savings on your dentistry etc. and it's a saving of up to 80% just visit wwweveryonebenefits.com/TammyC and look around let me know what you think?
Reply:Their job once you present your insurance card is to verify services. You can always make a copy of your bill, contact your insurance and file yourself. That way you know it is done. Contact your denitst's office and let them know what you are doing and that you are dissatisfied
Reply:It is absolutely your responsibility. It is your money that you pay toward your coverage, therefore the responsibility is yours to know what type of coverage that you have. We also file people's insurance as a courtesy. The office where I work is not a PPO with any insurance company, therefore we are not a part of anyone's network. However we can still file the insurance as a courtesy The patient is then responsible for their portion which the insurance does not cover.