Dental Insurance Is A Blue Cross To Bear

Thanks to some lying dentists, Georgena’s toothache turned into a real pain in the ass.

Due to a broken crown, she visited a Blue Cross Dental Insurance provider, Arlington Dental Group in Riverside, CA. They told her she needed two crowns and a bridge. She repeatedly asked if the work was covered by the insurance. They repeatedly assured her it was..

Guess what? It wasn’t.

What happened next, and our advice, inside.

Arlington Dental Group billed her and then threatened to turn Georgena’s account over to a collections agency. Under protest, she paid up.

Months of paperwork filing later, Blue Cross denied her claim.

Writes Georgena, “Blue Cross protects their providers and heaven help the poor patient.”

We want to knock Arlington’s teeth out, but Georgena also gets a finger wag.

If you don’t agree with a bill, don’t pay it. You’ll never get your money back. You might want to check out our post on drafting a good complaint letter. Lawyers are helpful, too and they’re quite talented at writing threatening letters. Here’s our post on finding a consumer lawyer. And we need hardly mention the imperative of getting anyone’s expensive promise in writing.

Medical billing disputes are the worst but you certainly have a better chance if you enter a dispute process than not trying at all.


Edit Your Comment

  1. adamondi says:

    Perhaps Georgena should have consulted the documents provided to her when she signed up with Blue Cross Dental. I know that every year when it comes time to renew my dental coverage, they give me a list of things that are covered and things that are not covered. She should have done her own research instead of simply relying on the people at the dental office to know the particulars of her plan and her coverage. You can never trust the providers to find that stuff out for you. They don’t care where the money for the work comes from. Georgena should have spoken to Blue Cross herself to get confirmation before ANY costly dental procedure.

  2. Drinker Nisti says:

    Read your plan before you have any work done.

    My general experience for anything beyond standard cleaning & x-rays: Insist on a pre-estimate review from your insurance. The dentist submits a dental treatment plan to your insurance. Insurance sends you and your dentist an estimate of benefits payable. The Insurance Co still has plenty of wiggle-room– you get an estimate, not an actual agreement for payment. However it should reduce surprises later on. (Or in my case, I get another round in the never-ending battle over whether my dentist is in-plan or out-of-plan… She’s in but they never update their &^#%! lists.)

  3. cooper says:

    I’m going to echo adamondi and Drinker Nisti on the knowing your own policy and add also that my experiences with Blue Cross have actually been very positive. Everyone has a story of course, but more than once Blue Cross has stepped up for me when I’ve been faced with a provider who did not want to follow the system. Health insurance is complicated, but Blue Cross (again, for me) has been really good about explaining my benefits when I call with questions. Plans tend to vary somewhat from company to company and there are always different levels of coverage — it’s always in your best interest to trust your plan material and insurance company over the service provider.

  4. Drinker Nisti says:

    Oh– one more thought: I work for a small company and our HR benefits manager gets lightning-fast response from the insurance companies. (Your employer’s the one paying the premiums & has the power to change insurance companies, after all…) If you have a sympathetic HR rep, s/he can probably get answers faster than you.

    When I worked at The Gigantic Corporation, HR would have just laughed at me and refered me back to insurance customer service…

  5. bradnh says:

    My perspective as a former practicing dentist and current attorney: I sympathize with Georgena’s task of interpreting her dental benefits, but it simply isn’t enough that she “asked (even if repeatedly) if the work was covered by the insurance.” What does “covered” mean in this context? Most dental benefits plans have a three-tier scheme of “coverage.” Typically, services such as cleanings, exams, and x-rays are covered 100%, twice per year. The next step up the coverage ladder are basic restorative services like “fillings,” and, depending on the plan, things like extractions and endodontics (root canals), usually at 80%, and often with certain restrictions ($2,000 max yearly benefit). At the top of the coverage ladder are things like fixed crowns and bridges. Even the best plans rarely cover more than 50% of these services. And, as Drinker Nisti describes, whether it’s required or not, getting a pre-treatment estimate of coverage is always the best protection. Bottom line, though, is that there is no way that virtually any insurance other than some very unusual gold-plated plan, was ever going to “cover” this if “covered” means 100% reimbursed. Finally, Georgena is just plain wrong that “Blue Cross protects their providers…” If she had no coverage, the provider is screwed, and is not getting paid by BC. That’s why most providers REQURE pre-treatment estimates, so there are no surprises, and REQURE the patient to pay her co-payment at the time of the service.

  6. Ass_Cobra says:

    Even knowing your plan and going through all the motions can result in getting next to nothing from your dental insurance provider. To wit:

    At my former employer I had Delta, I actually ponied up for the PPO vs. the HMO. The major factor in that was being able to go out of network and still getting 80% reimbursement. I went into the dentist as my mouth was killing me and it turned out that the root of a tooth I had injured and had a root canal on ten years ago was being reabsorbed by the jaw (very sci-fi, I was assured it was completely normal). Also it had started to become infected and there was a hairline crack between the root and the crown. The periodontist advised me that the root would have to be extracted and if I didn’t want to look like Cletus I’d need an implant.

    So I check my coverage, get the treatment plan and forward them off to Delta. Delta tells me that they actually don’t pre-clear things. I call shenanigans and they tell me to pound sand. Finally after about a week of non-stop calls they tell me they’ll look into it, but it usually takes them 6-8 weeks to turn that around. I explain that as we speak an infection rages in my mouth so six to eight weeks is really not an option. Just so no one gets confused, the initial plan (extraction and bone graft) encompass all of four procedure codes. In fact I ask them for a list of covered codes with my plan and they inform me that’s not for distribution. After banging on them a little longer, and the periodontist, who doesn’t accept insurance, because he has said they shaft providers worse than patients, explaining to Delta the deleterious effect of delaying treatment on my overall dental health Delta tells me to just roll the dice, get the procedure done and hope that they reimburse me.

    Not being one to play games with my good looks and health I go ahead and get the extraction. Total bill is in the neigborhood of $1200. Given the nature of the procedure (given the hairline crack, he couldn’t just yank the old tooth out, they actually had to cut the gum and cut the root out, very gross, he has the pictures to prove it) the $1200 seemed okay. I mean people do get charged $11 a pop for Tylenol in the hospital and I think this was worth more than 100 tylenols.

    I submit the final bill to Delta for the procedure (procedures) for reimbursement. They promptly send me a check for $110. I call and ask where the rest of the money is. They inform me that’s all I’m getting. They reimburse not on what you are billed but based on what they consider Usual Customary and Reasonable charges for the given procedure code. The catch is that they don’t publish what the UCR is widely and they won’t tell it to you before hand, at least not without waiting 6-8 weeks. It was an exciting time as I asked them how a dentist could be reasonably expected to make rent, doing extractions at 60 bucks a pop. They said their UCR charge was based on the average of the cost of a given procedure code in my area. I informed them that they may have my zip code incorrect as I do not in fact reside on the island of impoverished dentists. I will have to find the reimbursement summary, it’s a goddamned knee slapper. I mean if Dentists didn’t have to go to Dental School, carry insurance, cover staff and overhead like rent and equipment, then yeah, they may be able to get by charging what Delta considered UCR but they’d probably make more money tending bar or changing oil.

    I did raise holy hell with my HR department and they basically told me they’d see what they could do, it turns out they couldn’t do much. The fact that the UCR for a given procedure code is determined by the insurer and not subject to scrutiny is ridiculous. Bottom line, Dental insurance is a scam.

  7. Marsupial says:

    Wow — when I had Blue Cross Dental, I was with Arlington Dental Group in Riverside (whom I selected blindly, of course). I knew I needed major work, but when I got to the building, I freaked out. It looked like a painted over butcher shop coverted from a house. The staff was late getting back from lunch and, as I was standing at the back door waiting, I saw the (I assume) dentist drive up in his old beat-up car, and I knew that I had to get out of there. (My mother, who was visiting at the time, told me that she foresaw my death in that office.) My teeth ended up costing me $11K out-of-pocket at another location, but at least I didn’t die in a chair in Riverside.

    Besides, dental insurance is like VSP. It covers the bare minimum service. If you want anything above the lowest grade work (in my opinion), it’s a waste.

  8. bones says:

    Look, BCBS pays it’s CEO and other officers very well NOT paying your doctor or your dentist. Their entire profit is based on NOT paying claims. Your doctor and dentist constantly are told things are covered when in the end BCBS ends up denying payment. Consequently health care providers have come up with disclaimers they require patients sign stating you will pay if the insurance company doesn’t. I can’t count the number of times claims get denied FOR NO REASON, and you’re left with the insurance company’s interpretation of the policy. This is how insurance companies make money, promising the moon and delivering cheese, remember Katrina and non-payment of hurricane damage because the houses got wet so that’s flood damage and the homeowner’s insurance doesn’t cover flood damage. Same lies different insurance.

  9. Anonymous says:

    I went to the dentist for preventative care (x-rays, cleaning, exam) and in the BlueCross BlueShield handbook it stated it paid 100% for those services. I called to ask Bluecross and they confirmed this to be true, and I also asked if I had to go to a network provider, and the agent said there weren’t any network dentists, and I could go anywhere.

    So I had a booklet stating 100% would be covered and a verbal agreement that 100% would be covered. About a week after I went to the dentist I received a bill from the dentist and it stated that the insurance had only paid 37% of my claim.

    This is what BlueCross paid $21 on a $73 exam, $31 on a $75 cleaning, $40 on a $93 full mouth x-ray, and $12 on a $38 bite-wing x-ray. Leaving me to pay $175 on a $279 bill, which I thought would be 100% covered.

    I am angry because I checked the booklet and with the agent, and thought I was safely covered. In today’s economy people can’t afford surprises, and that is why I am filing this complaint as a warning for others.

    I believe they should pay the rest of my bill and will complain and post on sites until they do.

    Do Not Get BlueCross BlueShield Dental Insurance!