Who do I call when a dentist lies to me about my dental insurance paying a claim? I had to do a root canal, and my dentist at the time told me that my insurance plan would pay 50% of the cost of the root canal. He said the total cost was $800.00, but my cost would have only been $400.00. $400.00 is a lot of money, but I got that together to have the root canal he said I needed.

Yet when I got this bill in the mail, I was being charged $640.00 for the root canal instead of $400.00. I thought it was an error and called the dental office. They said my insurance plan did not cover as much as they thought, so I owe them $640.00. I called my dental insurance plan, and they told me that since I went to an endodontic, they cover 50% of the cost of the UCR, up to a general dentist’s cost. 

I called the dental office, who told me that the dentist in their office who did my root canal was a specialist, so that is why the claim got filed that way. I told him I would only pay the $400.00 stated to me when I was having the root canal done.

I am so upset I only did the root canal because of the price they told me I had to pay. I was bate and switched. I am still getting the billing for the difference and do not feel I should have to pay it, but they are stating they will put it on my credit report. Who do I call about this?

Reply:  In most cases, when a dental office provides a price based on your dental insurance plan benefits, they will inform you that it is still an estimate and will depend on what your insurance company pays. Most dental offices will charge you in full for dental services, or you may at least pay a portion of what they think your plan will not cover. When they do this, they will say any adjustment up or down will be billed or refunded to you, whichever the case is. 

Most PPO plans base coverage paid out by percentage—for example, 50 percent of the cost of major services. But that is only part of it. Coverage is also typically based on * UCR fees. These fees can occur when choosing an out-of-network provider, a dentist not in your rated area, and when going to a specialist. In your case, it was going to a specialist. Typically, the specialist cost for services will be higher than a general/family dentist, pushing you over the company UCR cost. All of this will be in the terms and conditions of your dental insurance policy. 

Your dental office gave an estimate of cost based on the basic coverages your plan provides, which is not a case of a lying dental office. Understandably, you are upset due to the unexpected costs of having your dental care. Whether this is a miscommunication with the dental staff providing the cost is unclear. It seems as if you were not fully aware of your dental insurance plan benefits and did not ask all the questions needed to understand the cost of having the services rendered. Regarding who you can call about the additional cost, I have no advice to provide you after the fact.   

I do have a suggestion moving forward. Most insurance companies will do a * predetermination of dental benefits. Many encourage you to submit a predetermination of dental benefits for any service over $300.00 to help avoid this issue you are currently having.  

• Usual, Customary, and Reasonable

• A predetermination of benefits is a written estimate from your dental insurer of the amount your dental plan will pay for a specific treatment based on information provided by your dentist.