Health Insurance question: copayment calculated by what?

Question

I had a service done for crown on tooth. My Aetna dental plan covers 60% of charges for such service leaving my copayment at 40% of charges.

So I get the crown. The dentist submits claim to Aetna for $955 for this service. Well Aetna has struck a deal with numerous dentits in area and "Charges at Aetna's Agreed Pricing" for this service are $812 for Aetna members as myself, and not the $955 they would charge an uninsured person.

Aetna says my responsibliy is 40% of charges, no complaint there. My complaint is they say that's 40% of $955 or $382. Then Aetna pays the balance which is $430. ( $812-$382 = $430) So the dentist gets his $812 which is the agreed to price for service, Aetna pays $430, I pay $382, how is that a 60/40 split that really is 53/47 split and i'm out $57.20.

Am i being scammed or what? I already emailed Aetna and of course they are claiming that's how it's done, but i think they are scamming me. What do you think?

Answer 1

I used to work in insurance and that doesn't sound right. The difference between what the dentist actually charged and what Aetna's allowable amount is should actually be a discount that you should not be responsible for. If the dentist has agreed to the 812 that's because they have a contract with Aetna that they need to adhere by. They only other thing I can think of is that the $143 difference is over the usual and customery rate for your area which in that case you would owe that money. I would contact Aetna again and ask them to explain whether that 143 is a discount or if it's over usual and customary.

Answer 2

You are talking about co-insurance not co-payment.

Your 40% would be of the agreed upon charge of $812

If your dentist is in the Aetna network he is not allowed to charge you more than the $812. If he is not in the network Aetna pays thier 60% and you pay the rest because you chose to go out of network.

Your 40% should be on the $812. I have never seen it done any other way. Did you get an EOB from Aetna?

Answer 3

Agree with the other responder.  You pay 40% of the negotiated fee, not 40% of $955.  And your EOB should have the details.  Scan the insurance booklet you were given, and if there is still a question contact your HR representative at work.

Answer 4

You should be paying 40% of the $812.

Don't forget, you also might have a deductible, or a "maximum benefit" for the calendar year, which could be interfering with the calculation.

Or the person you talked to is rotten at math.

I'd call Aetna, and talk to someone else.  I wouldn't do the email thing.