I recently had some dental work done. I had to get a few wisdom teeth removed. I was in some pain and was not in much of a mood to slow down and evaluate the process the dentist was recommending. I almost made a gigantic mistake but we were saved by a friend with special insider knowledge. I am going to give you some of that knowledge right now.
You need to know what happened.
Read on...
It is Orange County, CA, 2024, and I had selected a dentist who was "in network" meaning they have an agreement with my insurance plan. They evaluated my situation (extraction of three teeth) and said it was going to be about $2,300. They set me up right there in the office for a payment plan with Lending Club and I was scheduled for surgery in about a month. The first payment for the yet-to-be-performed surgery came in a few weeks and I was thinking, hmm, this seems weird. I called the office and they said that was normal. My wife got more suspicious than I did because I rarely go to a doctor or a dentist for anything more than a checkup, so I did not know that this was NOT normal.
That's when she started talking to her friend who saved our butts. This friend who we will call "Joni" used to work for a doctor's office and for an insurance company and she told us to put everything on hold because the dentists was stealing from us.
Joni said flat-out that $2300 seemed very high for a few teeth to be extracted. She said to first make sure the involved technicians (dentist, anesthesiologist, surgeons) are ALL in network. Because, guess what, if one of the team of medical people in a procedure is "out of network" then the ENTIRE procedure is billed "out of network" so your "in network" dentist can now bill whatever they want.
My wife, bless her, called the dentist for me and found out that, "Gosh, we put you with an out-of-network doctor, oops!" Now, I had been asking throughout this process if the doctor was in network and the answer seemed to be "yes" each time so I was not worried.-- they totally have my back, right? Well, no, they often care not about "your back."
After they reorganized the procedure to fix this "error" and got me set up with in-network surgical people, it still seemed an abnormally high cost. They explained to my wife that, "Well, the insurance only covers this much but we charge this much so you have to pay the balance. Joni said that this practice is called "balance billing" and is ILLEGAL for a doctor to do when they have contracted with an insurance company. (don't worry, I will lay this out in bullet points at the end)
Joni instructed my wife to call the office and use the words: "That is illegal and you cannot charge over the contracted rate." The answer was, "Oh, gosh, you are right. We will 'resubmit' the claim." We found out from Joni that "resubmitting" a claim basically means, "Oh, they caught us stealing, let's redo it correctly this time." We eventually arrived at the insurance-contracted rate which was somewhere around $287.
Yes, they were financing me for $2,300 and I was making payments BEFORE THE SURGERY ( an illegal practice for insurance-contracted doctors). They applied the payment I had already made on the illegal loan to that bill so we ended up only paying less than $300 for the procedure.
Quite a saving yes?
Months later, a friend of mind went in for his scheduled colonoscopy and they said, "Yeah that will be $1100." He was stunned and had to lay down a credit card. I knew something was up, thanks to my recent experience, and told the wife (who had become a bit of an expert now) and she said, "Hell no." She instructed my friend to call his insurance company and ask about it and, lo and behold, it came out that the doctor's office had "used the wrong billing code" and it was actually only $100. Oops! Well, he got a refund.
THIS IS COMMON PRACTICE.
Let's recap. Here are a few easy ways to remember what you should do in the event you need a medical procedure beyond of that normal doctor visit for a bad cough or earache.
Check if Provider is In-Network:
Call your insurance or check their website (calling is better) to make sure the provider is IN NETWORK. Do not mess with an out-of-network doctor -- unless you are very certain what the price is going to be and maybe you know this person and they have some specialty that you know is gonna be worth it for you.
Get an Evaluation From Doctor
They need to evaluate your situation and see what is needed. If the copay is appropriate then things are looking legit so you can proceed with evaluation, if they charge more for that then something may not be right.
Surgery Predetermination:
Before any services, ask the doctor to submit a "predetermination" to your insurance. They'll need to provide their tax ID, CPT codes, and medical records. Insurance will likely take weeks to respond with a letter of predetermination, so expect that.
If Doc Refuses To Do a Predetermination:
Get the doctor’s tax ID, CPT codes, and the name of the surgeon. Call your insurance with this info to verify network status and expected costs.
Watch Out for Extra Charges:
Doctors might claim they charge more than what insurance states, but if they're in-network, they can't legally charge you the difference. This is the "balance billing" I referred to earlier. They are not allowed to do this.
Extra things to remember: If ONE member of the surgical team is out of network then the whole surgery is billed "out of network" and "balance billing" is where they try to charge you MORE than the rate they contracted with your insurance provider.
Emergency procedures are rather a different animal and one cannot expect you to be able to do these things if you crack your head open on the street and are unconscious. Happily there seem to be safeguards set up for this and hospitals will have to figure out all that stuff in case you are incapacitated because most likely if they over charge you without your consent they open themselves up to legal challenges. SO they are rally protecting THEMSELVES in that case so they will actually do the work. Remember if they trick you into agreeing to an out-of-network procedure or a "balance billing," then you are on the hook and it will be very hard for you to set things right.
I hope these tips help you as they did me.
To tighten it up even a more, remember this little acronym
N.E.P. (Network, Evaluation, Predetermination)
Bookmark this article and refer to it because eventually as Father Time does his dastardly work on us all, the time will eventually come where you need this information.
Comments from people in the medical and insurance industry are appreciated here. Do let me know if I got anything wrong.
