Does anyone know about insurance eligible charges for a doc.?

Question

If a doctor agree's to be a prefered provider does he get to charge u more than the insurance co. sais he can??? My dendist charges me way more then my insurance covers and I was told by my insurance co. that they are not charging the agreed amount, but didn't tell me if its ok for a doc to do that..

Answer 1

A preferred provider, as it sounds like you dentist is one, agrees to accept the insurance companies payment as 'payment in full' AFTER your deductible or coinsurance - if either apply (and assuming the services provided are covered by your insurance plan).  The amount he/she submits to the insurance company is irrelevant.  Let me give you an example:

1.  Your have a $25 deductible and your insurance pays 90% and you are responsible for 10% of all covered charges.  You go to the dentist for a cleaning and xray and he charges you $75 for the cleaning and $125 for the xrays and submits a $200 bill to the insurance company.

The claim is processed and the dentist receives the following information:

Eligible charges - Cleaning = $50

Eligible charges - Xrays = $50

Patient responsibility = $25 (deductible)

Remaining balance = $75

Patient responsibility = $7.50 (10% of 75, your coinsurance)

Insurance company pays = $67.50

Non-allowed charges = $100 (difference between what the dentist charges and what the insurance company allows)

Total patient responsibility = $32.50 (deductible of $25 and coinsurance of 10%)

If the dentist is preferred they should only bill you the amount the insurance company authorizes, NOT THE nonallowed charges, they are written off.

Total insurance payment = $67.50 (90% of remaining balance)

Answer 2

Sounds like this doc is NOT in your insurance company's preferred provider network.  Better reverify.