Dental Insurance not keeping up with $$

[PWMDMD]

Corporate jets with millions of dollars worth of complex systems that affect life, limb, and public safety is a pretty vast difference from a medical practice. Stuff costs money. Ok. That’s why most folks don’t have a corporate jet.

Expectations far on the other end are annoying too. Someone making a fuss after being told a price and being promptly provided a service is horrible. It’s nature of the beast I guess for anything public-facing, but it’s not fair.

But the interesting thing you mentioned was the cost to do a variety of setup steps. Ok so you think it costs $85. I suspect that if I came in tomorrow, you would charge me/my insurance $250 for it, in expectation of them coming back and saying that they’ll pay $70.

What’s not clear to me, and one of the most frustrating things to me as I use an HSA/HDHP, and thus pay much more out of pocket and are more in tune with costs…. Is why anyone can’t get a straight up price, straight up, to make decisions and compete on. It’s not an easy process. There’s lots of ambiguity. The scale sliding so broadly for a service is insanity.

My pregnant wife went for some tests. Her OB said they would be around $250 each. The test company billed somewhere on the order of $3500 each, and insurance denied it as necessary (I pay it myself kind you with an hdhp). My wife called and asked about this, and indicated the cost that the OB stated. The test company quickly replied that if that’s what they said, they would rebook at $249 each, which we paid.

Obviously the test company can’t stay in business on such “goodwill”, thus it’s all just opportunistic billing. I recall seeing similar for the last day in the maternity ward with my first. Somehow the hospital thought that day was worth $69k though it was just the one extra day allowed after a c-section. It was denied abs insurance somehow “magically” made it go away.

Have tons more of these stories, and we’re healthy and rarely need to go to a doctor. So it’s just wild to me to have any confidence in the reality of any pricing for anything.

We accept insurance reimbursement but we are out-of-network with all insurance. So $85.00 is my price for the exam no matter what someone's insurance will pay. If you don't have insurance then it's $85.00. If you have insurance then it's $85.00 minus whatever your insurance will pay - you owe the difference. For every single treatment plan, the patients get a printout of our price, what their insurance will pay, and what they owe. I can't make it more transparent than that. If you are in-network and your fee is $85.00 and insurance pays $40.00 then you have to accept $40.00 - you can not balance bill.

What this means as a patient is while your out-of-pocket is generally more with an out-of-network provider there are some advantages. In the above example, since the practice is actually being paid what they need to make to cover overhead (and hopefully then some), margins are not as tight and we don't need to "maximize" billing to insurance by recommending everything possible. Oftentimes, the practices that over-treat do so because they are writing so much off to insurance they almost have to if they want to make any money. I don't need to do this since I get my full-fee one way or the other. I also don't have to overbook the schedule. If I run behind more than 5 mins 3 or 4x per year that would be a lot. Most of the time we are ready to go and waiting for the patient to get there. The end result, my patients may pay more per procedure but as I said before I don't look at them thinking what can I bill them - it's more what do they need - in the end I think they pay more per procedure but I probably recommend fewer procedures and in the end they pay less.

There are few similarities between billing in medicine and dentistry. For instance, I've seen my medical insurance get billed $2500 for something and the actual reimbursement was $250. If you have insurance, the hospital accepts $250 but if you don't you owe $2500. There is no where in dentistry where we charge 10x what we'd be willing to accept from insurance. Typically, even in-network insurance is paying 50-80% of the fee.