Who was right? Dentist or insurance company?!
Question: Who was right!? Dentist or insurance company!?
My dentist advised me that I required bone graft to fill a very deep pocket!. The insurance company (GUARDIAN) refused to pay; they said they've reviewed my X-ray and determined that I didn't need it!. Now I'm stucked with a $300 bill!. Guardian said my dentist could send in a written explanation to appeal!. I'm not sure he has done that, I think he just sent me the bill!. What should I do next!?Www@Answer-Health@Com
Answers:
An insurance company will do whatever they can to refuse to pay a claim!. Why wouldn't they!? That is how they make money of their clients!.
I have seen insurance companies refuse to pay claims based on ignorant reasons!. Claims for crowns have been denied because the insurance company thinks the dentist should have put a really large filling in a tooth instead!. Insurance companies refusing to pay for tooth colored fillings because they think the dentist should have used silver colored amalgam!.
My sister-n-law used to work for Cigna dental as a claims processer!. She told me that the people who review claims and decide if Cigna will pay for them are called claims specialists!. She said that all a person has to do to be hired as a claims specialist, is to have at least 7 years chairside experience!. I don't know that I would appriciate a person with 7 years dental assisting experience deciding what kind of dental work that I needed to have done, and saying that my dentist was wrong!. To me, that isn't enough dental knowledge to know what a patient needs or doesn't need!.
My office manager knows a woman who used to work for another major dental insurance company, and this woman said that they were told to trash claims numerous times!. Meaning that the claims never even got reviewed for payment!. They were simply thrown away!. Resulting in the dentist having to refile the claim!. They would also get into trouble for approving too many claims for payment!. They were told to deny a certain amount of claims!. That doesn't seem fair in my opinion!. But how do you prove that!. An insurance company is never going to admit to doing something that underhanded!.
Did the treatment work!? Did it improve the depth of the periodontal pocket!? If so, then your insurance company is the one who is wrong!.
You should request that your dentist write a narrative to the insurance, informing them that unless a licensed dentist has reviewed the xray and perio chart on you, then someone at their insurance company is illegally diagnosing dental work, and that the dentist will report them to the state insurance board!. My office has done this numerous times, and 9 out of 10 times, we get paid by the insurance company!.Www@Answer-Health@Com
I have seen insurance companies refuse to pay claims based on ignorant reasons!. Claims for crowns have been denied because the insurance company thinks the dentist should have put a really large filling in a tooth instead!. Insurance companies refusing to pay for tooth colored fillings because they think the dentist should have used silver colored amalgam!.
My sister-n-law used to work for Cigna dental as a claims processer!. She told me that the people who review claims and decide if Cigna will pay for them are called claims specialists!. She said that all a person has to do to be hired as a claims specialist, is to have at least 7 years chairside experience!. I don't know that I would appriciate a person with 7 years dental assisting experience deciding what kind of dental work that I needed to have done, and saying that my dentist was wrong!. To me, that isn't enough dental knowledge to know what a patient needs or doesn't need!.
My office manager knows a woman who used to work for another major dental insurance company, and this woman said that they were told to trash claims numerous times!. Meaning that the claims never even got reviewed for payment!. They were simply thrown away!. Resulting in the dentist having to refile the claim!. They would also get into trouble for approving too many claims for payment!. They were told to deny a certain amount of claims!. That doesn't seem fair in my opinion!. But how do you prove that!. An insurance company is never going to admit to doing something that underhanded!.
Did the treatment work!? Did it improve the depth of the periodontal pocket!? If so, then your insurance company is the one who is wrong!.
You should request that your dentist write a narrative to the insurance, informing them that unless a licensed dentist has reviewed the xray and perio chart on you, then someone at their insurance company is illegally diagnosing dental work, and that the dentist will report them to the state insurance board!. My office has done this numerous times, and 9 out of 10 times, we get paid by the insurance company!.Www@Answer-Health@Com
Call the dentist's office to inquire about the state of your request!. If the dentist said you should get it-- he should have no problem writing to the insurance that you DO actually need it!. If the dentist is a good one (who doesn't prescribe something you don't really need) they should be willing to fight the insurance company to cover it for you!Www@Answer-Health@Com
Contact the dentist and tell him you want him to appeal, explain to him you do not see that you should have to pay out of pocket for something he said was required so now he needs to back up what he told you!.Www@Answer-Health@Com