After many years of terrible neglect, I
overcame my avoidance of dentists. It was
in large part because of $$, but also
because of bad experiences.
So now I have what seems to be good
insurance and a good dentist. She filled a
zillion cavities and seemed efficient and
competent.
To complete the project, I need three root
canals (3, 30 and 31). She doesn't do the
actual root canals on molars, so is
sending me to a specialist for the D3330s.
Here is the problem: The costs according
to the benefit schedule seems clear, but
she's tacking on misc D999 fees.
My insurance:
http://www.compbenef
its.com/custom/stateofflorida/Network-Plus
-DHMO_Sched-Lim_Exc.pdf
It would seem that my fees would be (per
tooth):
-D3330 - $64 (at Endodontist, already
confirmed cost. They say they get a decent
reimbursement .)
At dentist:
-D2950 Crown Buildup- $59
-D2790 crown - $150.
Pretty darn good, but she's adding D999
"unspecified procedures" of $150 per tooth
for "lab fees", and another D999 of $101
for "study models" once. Can she do that?
She says that the copays don't cover the
costs, so she has to add the extra fees.
As far as I understand, I have an
agreement with the insurance company that
the listed items cost as listed. She has
an agreement with the insurance company to
provide services for the prices listed. So
to do otherwise is a breach of the
agreement.
I can understand that if a dental code
isn't listed, like I believe that a cavity
can be "lined" prior to filling and that
my insurance doesn't cover it. So that's
an actual dental coded procedure that she
thinks is medically necessary, but isn't
covered. OK, but just gluing a fake D999
because she wants more money seems
unethical.
From what I understand, it's a roster type
insurance. She gets around $12 or $13 a
month no matter what she does. Then there
are very low co-pays for many procedures
($6-$13 per cavity, depending on number of
surfaces, etc). A ton of procedures are
free for me.
So for people like me with crappy dental
hygiene and a ton of problems, I'm not a
good patient financially for her. But if
she has 3000 patients, she gets ~$36K a
month. If she can keep people healthy she
might do OK. For every crap patient like
me there are some "good" patients (just
need cleanings or doesn't come at all). It
will balance in the end if she's efficient
with issues as they come up. Now that she
fought off all the issues other than the
root canals, I should be good for a
while.
So is this acceptable practice? Should I
push it with the insurance company? If I
fight it and am able to force the issue,
it's going to make for some awkward open
mouth sessions.
For me, it makes the difference of getting
it done, or continuing to let it slide
because I can't afford it.
