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.compbenefits.com/custom/stateof
florida/Network-Plus-DHMO_Sched-Lim_Exc.pd
f
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.
