<p>Any wisdom regarding contracted rates vs. full pay rates when annual max has been reached?</p>
<p>I had quite a bit of dental work done last year and reached my annual maximum benefit allowance. The last procedure was for an implant abutment and crown, for a total of $2350 which I paid out of pocket. My insurance carrier’s contracted rate is $1750 but the dental office says that because the insurance denied the claim I have to pay the full rate. The EOB states my responsibility is $1750. I would think that they would still need to honor the contracted rate. </p>
<p>I’m already on the verge of reaching my max again this year so really would like to know what I should be paying out of pocket for the rest of the year…full pay or contracted rate? </p>
<p>Start looking for another dentist. I’ve been seeing the same one for 13 years, and on years where we maxed out our benefits, all subsequent work was done at the discounted rate. If they had jacked it up, I’d have felt used. Don’t bite the hand that feeds you, seems to be my dentist’s mantra…smart guy!</p>
<p>I agree, I switched dentists two years ago after I got into an argument with the office manager about what I perceied as price gouging after I had thousands and thousands of work done after I exhausted the benefit. I know for fact that the dentist has no idea what his office manager is doing. I’ve bumped into him socially a few times and had to bit my tongue not to tattle on his office manager. </p>
<p>The office manager who did the billing last year is gone. When I called this morning and questioned the new office manager she suggested I call the insurance company. Insurance company told me that every state is different, but that in my state it is a law that they have to stay with the contracted rate. </p>
<p>I have an appointment in a few hours for a post, core and crown. Now I’m afraid to go! Will he be as gentle when he knows I’m taking money out of his pocket? Really though, I like and trust this guy. I hope we can work out!</p>
<p>I do not know if this is happening. I am not accusing anyone of stealing. </p>
<p>This scheme is one way for an office manager to embezzle from their employer. </p>
<p>Office managers embezzling from physicians happens more often than you think. Again I am not accusing that this happened and this may be the policy of the dentist. If it is, look for a new dentist. ASAP </p>
<p>Talk to the dentist. Really. It would be unusual for the office manager to own the practice. The dentist probably owns the practice, and the dentist should be involved in issues like this. “I know I need to have this work done, but I’ve reached the cap on my insurance. The insurance company says I’m not supposed to have to pay more than their allowed charge of $x, but Ethel has told me that because I’m paying myself I now have to pay $x+y. I really don’t want to leave the practice, but this is not working for me.”</p>
<p>Call the insurance company again. This happened to me once with medical insurance where a provider charged more than the insurance company determined was my responsibility. The insurance company rep called the provider with me on the phone, explained what the provider had contracted to accept, and the provider adjusted the bill.</p>
<p>I think if they (the health care provider) have a contracted rate with an insurer, they have to accept payment for the contracted rate, whether that comes from the insurance company or you. In fact, if they bill you differently, they can be in trouble with the insurance company. </p>
<p>Thank you all for your input! The problem is resolved. They will be charging only the contracted rate from now on and will credit me the error from last year.</p>
<p>It turns out that the rules on this vary by insurance company and the laws vary by state. I was finally able to contact a friend who is a manager for a dental office in Mass. She told me that in Mass they do not have to honor the contracted rate once the benefit max has been reached. However, in NH, where I am, they do have to honor the rate. She further stated that many NH offices will claim to be “unaware” and will bill full price unless the patient questions it!</p>
<p>I started a thread a few months ago about being nickel and dimed by big businesses and medical practitioners. This would have fit in well there!</p>