Question - re having primary and secondary dental insurance

[Deleted]

My head is spinning trying to figure this out. 

H carries dental insurance. It's fine for basic care stuff, but not great for major procedures. He has $1500 in annual coverage, and the plan pays 50%. 

I also carry dental insurance, so it would be his secondary. My plan has up to $2500 in annual coverage, at the same 50% payment rate.

I'm trying to just estimate our out of pocket with a dental implant he needs to get done. The quote (with no insurance) from the provider is $3140. So assuming that his plan pays 50% up to the $1500, that would leave a balance of $1640. So when my insurance is billed, are they billed the $1640 and then pay half of that so $820, or are they billed the full amount as well and conceivably pay 50% of that which would be $1570? Or is it something completely different?

H gets all panicky about money, and we have the savings to pay the difference in either scenario, but I'd like to try and help allay some of his financial worry and give him an estimate. 

[Pilsy]

I'm eager to learn how this works. I've never had secondary insurance, but I've always assumed something like this might vary by plan.

My guess is that they'll pay as little as possible, but that's very cynical of me.


Sorry I'm not helpful!

[thebreakfastclub]

I don't know much about having two policies, or why you would want to do that? Can you not just have one policy that covers you. I know nothing about insurance but if everyone could double up insurance like that, lots of people would, to get double ortho benefits and stuff like that.

At any rate, I did have a dental implant in 2019 so I can speak to that.

I just want to caution you that most of the surgeons were out of network, and the insurance reimbursement was more like a third of the total bill.
Also, the implant is one part of it, you then need to pay your regular dentist for the crown that goes over top and get reimbursed that way.

They had me pay a bit at each step, then insurance was billed at the same time, and when it was done I got a $600 overpayment check from my surgeon. That was for sedated extraction and the implant itself.

[spindle92]

Well the first thing is does your insurance cover implants.
A lot of plans do not.

If it is covered by both plans then Plan A is billed the full amount and pays whatever they pay and then balance is billed to plan B and they pay whatever they will cover.

[Deleted]

Mar 22, 2021 14:08:17 GMT -5 thebreakfastclub said:

I don't know much about having two policies, or why you would want to do that? Can you not just have one policy that covers you. I know nothing about insurance but if everyone could double up insurance like that, lots of people would, to get double ortho benefits and stuff like that.

So, H carries our health insurance, vision, and dental. However, his Dental doesn't have any benefits for Orthodontia so I picked up Dental coverage through my work that has coverage for braces. That was the original reason. I've been carrying this second policy for 3.5 years now, and with 3 kids that needed braces, we're still coming out ahead. I never even thought about having the double coverage for other things, but after speaking with my kids dentist as well as my own, it's totally legit. There is something called a Coordination of Benefits that is generally outlined in policies for just this reason. That said, I tried reviewing the coverages on both dental providers websites and can't seem to get a clear picture of how things work for major work like crowns and implants. 

[Deleted]

Mar 22, 2021 14:12:06 GMT -5 spindle92 said:

Well the first thing is does your insurance cover implants.
A lot of plans do not.

If it is covered by both plans then Plan A is billed the full amount and pays whatever they pay and then balance is billed to plan B and they pay whatever they will cover.

I did check, and they both do as long as it is not cosmetic.

[thebreakfastclub]

Mar 22, 2021 14:14:25 GMT -5 @sameoldstory said:

Mar 22, 2021 14:08:17 GMT -5 thebreakfastclub said:

I don't know much about having two policies, or why you would want to do that? Can you not just have one policy that covers you. I know nothing about insurance but if everyone could double up insurance like that, lots of people would, to get double ortho benefits and stuff like that.

So, H carries our health insurance, vision, and dental. However, his Dental doesn't have any benefits for Orthodontia so I picked up Dental coverage through my work that has coverage for braces. That was the original reason. I've been carrying this second policy for 3.5 years now, and with 3 kids that needed braces, we're still coming out ahead. I never even thought about having the double coverage for other things, but after speaking with my kids dentist as well as my own, it's totally legit. There is something called a Coordination of Benefits that is generally outlined in policies for just this reason. That said, I tried reviewing the coverages on both dental providers websites and can't seem to get a clear picture of how things work for major work like crowns and implants. 

Because the implants can be so $$$, I sat with the office's financial person immediately after getting out of my consult, to outline what was due when and how payment worked.  I would maybe try the office itself, and talk to them about the coordination part.  I bet they will have some insight specific to implants.  Good luck!

[Deleted]

Mar 22, 2021 14:17:28 GMT -5 thebreakfastclub said:

Mar 22, 2021 14:14:25 GMT -5 @sameoldstory said:

So, H carries our health insurance, vision, and dental. However, his Dental doesn't have any benefits for Orthodontia so I picked up Dental coverage through my work that has coverage for braces. That was the original reason. I've been carrying this second policy for 3.5 years now, and with 3 kids that needed braces, we're still coming out ahead. I never even thought about having the double coverage for other things, but after speaking with my kids dentist as well as my own, it's totally legit. There is something called a Coordination of Benefits that is generally outlined in policies for just this reason. That said, I tried reviewing the coverages on both dental providers websites and can't seem to get a clear picture of how things work for major work like crowns and implants. 

Because the implants can be so $$$, I sat with the office's financial person immediately after getting out of my consult, to outline what was due when and how payment worked.  I would maybe try the office itself, and talk to them about the coordination part.  I bet they will have some insight specific to implants.  Good luck!

Thanks. The office gave us a quote for the Implant (not including the Crown, the Dentist will do that) and said that they'll call the insurance company 1-2 weeks before the procedure (as a courtesy) to obtain our estimated cost. I'm just trying to get an idea before hand so I know what to plan for. Our estimated cost will be due at the time of the procedure so I don't want to be shell shocked 1 week out if you know what I mean. 

[Deleted]

Mar 22, 2021 14:05:00 GMT -5 Pilsy said:

I'm eager to learn how this works. I've never had secondary insurance, but I've always assumed something like this might vary by plan.

My guess is that they'll pay as little as possible, but that's very cynical of me.


Sorry I'm not helpful!

You'd think! When my kids go to the Dentist, they bill the primary (mine) and then send the EOB to the secondary to see what they'll pay. For some reason, the secondary keeps paying the "reasonable and customary" cost of the full bill instead of just the unpaid portion. It's very frustrating and causes us to constantly carry a credit on our account. The Dentist office doesn't want to play intermediary, which I get, so then I have to step in and deal with the insurance company to get them to accept a partial refund.

[fiddles]

This won't help but, it all depends.

I'm double insured for my dental and my secondary picks up 100% of whatever is leftover. Not all dentist insurances are this way though. You'll also want to make sure that your dental allows for you to have secondary insurance.

[sent]

My staff handle 95% of insurance stuff. But the claims where the patient has two insurances that both have orthodontic benefits come to me for billing and follow up. From an administrative perspective they require a lot of paperwork, organization and phone calls to make sure they pay everything owed.

You would think there would think the insurances would always pay so the patient will financially benefit from both plans but it doesn’t always work that way. The secondary insurance can have rules such as “standard coordination” or “non duplication of benefits” and some others that affect how they pay, how much they pay or if they even do pay.

I’m on my phone, I will read over your situation when I’m on my computer and see if I can offer any other insight.

[sent]

Is the dentist in-network or out-of-network for both of the insurances or a combination? This will also affect how they pay.

[WOT?*]

Mine is a little different than standard two-jobs type coverage but what our primary doesn't cover is fully covered by secondary (state insurance from foster/adopt negotiations so not quite the same issues as double-coverage from two jobs.) I haven't had to pay a co-pay or medications since they were placed with us, even after the foster program was no longer in effect.

I'd read what your policy says w/r/t secondary coverage. Or call and ask your insurer.

[sent]

Mar 22, 2021 13:57:46 GMT -5 @sameoldstory said:

I'm trying to just estimate our out of pocket with a dental implant he needs to get done. The quote (with no insurance) from the provider is $3140. So assuming that his plan pays 50% up to the $1500, that would leave a balance of $1640. So when my insurance is billed, are they billed the $1640 and then pay half of that so $820, or are they billed the full amount as well and conceivably pay 50% of that which would be $1570? Or is it something completely different?

Ok, so I just read this over. I do not bill implants, but the process is the same. Typically the primary insurance is billed $3140. The primary pays what they will, and then the EOB from the primary is sent with the same exact claim form for $3140 that was sent to the primary over to the secondary. Then the secondary looks at the EOB & claim form and decides what they will or won't pay. In the best case scenario, They will pay the full 50% of $3140 and you will owe very little out of pocket. It all depends on how the secondary coordinates with the primary (this is a policy decision made by the seconadary insurance and your employer) and on if your doctor is in or out of network with the two plans. If he or she is out of network, they don't always automatically consider $3140 as the fee they will use to pay the 50%. Insurance companies have their own "max" fees sometimes that will be less than $3140 and will only pay 50% of the insurance max leaving you responsible for the rest (this is called balance billing). 

So basically you won't really be able to predict until everything processes and pays out. Maybe someone in the billing department has encountered other families who have your employer's plan as the secondary and could give you more guidance on how they will pay. 

ETA - is the $3140 the full fee for the implant or a combined fee of different codes involved with the implant (bone graft, there may be other codes they are billing). Because then it is more complicated. Each plan may or may not cover the various codes in which case you really won't know until everything pays and processes. And this is why many offices won't deal with the secondary insurance and hand the paperwork over to the patient. 

[sent]

Mar 22, 2021 14:08:17 GMT -5 thebreakfastclub said:

I know nothing about insurance but if everyone could double up insurance like that, lots of people would, to get double ortho benefits and stuff like that.

LOL, since 2020, I have been getting more kids with double ortho benefits from the parents. All the kids are still in treatment and the claims are still paying since most ortho policies pay out little chunks of the benefit over time.  So I still can't give anyone any insight on how much the secondary will pay because I am learning as we go. 

But I'm not going to complain because this is a very good problem for me to have! And I like the challenge of figuring out how to make the billing more efficient from my end so I can provide better estimates to my families. 

WOT?* , I've had a few families over the years that have the situation you described. The children are adopted from foster care so they have the state insurance regardless of parental income, but their parents also carry dental for them which becomes the primary. The families often come to us because we are in-network with both. 

[sdlaura]

We have dual dental insurance through both of our jobs and it’s amazing. It’s so nice to not pay much out of pocket even when we need major work done. I’ve always had our dental offices figure out what things will cost me out of pocket, before procedures.

[4speedy]

Mar 22, 2021 22:17:12 GMT -5 sent said:

Mar 22, 2021 13:57:46 GMT -5 @sameoldstory said:

I'm trying to just estimate our out of pocket with a dental implant he needs to get done. The quote (with no insurance) from the provider is $3140. So assuming that his plan pays 50% up to the $1500, that would leave a balance of $1640. So when my insurance is billed, are they billed the $1640 and then pay half of that so $820, or are they billed the full amount as well and conceivably pay 50% of that which would be $1570? Or is it something completely different?

Ok, so I just read this over. I do not bill implants, but the process is the same. Typically the primary insurance is billed $3140. The primary pays what they will, and then the EOB from the primary is sent with the same exact claim form that was sent to the primary over to the secondary. Then the secondary looks at the EOB & claim form and decides what they will or won't pay. In the best case scenario, They will pay the full 50% of $3140 and you will owe very little out of pocket. It all depends on how the secondary coordinates with the primary (this is a policy decision made by the seconadary insurance and your employer) and on if your doctor is in or out of network with the two plans. If he or she is out of network, they don't always automatically consider $3140 as the fee they will use to pay the 50%. Insurance companies have their own "max" fees sometimes that will be less than $3140 and will only pay 50% of the insurance max leaving you responsible for the rest (this is called balance billing). 

So basically you won't really be able to predict until everything processes and pays out. Maybe someone in the billing department has encountered other families who have your employer's plan as the secondary and could give you more guidance on how they will pay. 

ETA - is the $3140 the full fee for the implant or a combined fee of different codes involved with the implant (bone graft, there may be other codes they are billing). Because then it is more complicated. Each plan may or may not cover the various codes in which case you really won't know until everything pays and processes. And this is why many offices won't deal with the secondary insurance and hand the paperwork over to the patient. 

As an American living overseas, we had a discussion about this at dinner one night with our neighbors (2 American families, 4 families from other countries). The 4 other couples were absolutely astounded about our medical/dental billing practices.  The rest of the world, apparently, just can’t believe there is no way to tell how much a procedure will cost the patient until after it is done and billed and then the patient pays whatever the insurance company decides not to.

Also, I have GeoBlue, which is the international version of Blue Cross, for my dental care over here.  I had an implant done a year ago.  I was told my treatment plan cost on day one, right down to the penny. It did not change at all over the course of treatment.  I don’t know why an American insurance company can tell you up front what you’ll pay overseas but can’t manage to do the same in the U.S.

rant over.  OP, I sympathize with you.  Dental bills suck.

[4speedy]

OP, does the timing of the procedure make any difference? For instance, after the tooth is extracted, you wait for a while for it to heal, then the implant is put in and you wait many months for the bone to fill in and harden around the screw part, then the crown is made. If you were to start in June but finalize the crown part the following January, would that help or hurt you? Can you spread the insurance billing over two benefit years? I have no idea if this is something that is done, just throwing it out there in case someone else knows.

[sent]

Mar 23, 2021 1:06:15 GMT -5 4speedy said:

.  I don’t know why an American insurance company can tell you up front what you’ll pay overseas but can’t manage to do the same in the U.S.

rant over.  OP, I sympathize with you.  Dental bills suck.

They can absolutely tell us. They don’t want to because it will maintain driving the wedge between the patient and doctor. They share bits and pieces with us as private practice doctors and we have to fill in the holes ourselves.

[4speedy]

Mar 23, 2021 2:24:35 GMT -5 sent said:

Mar 23, 2021 1:06:15 GMT -5 4speedy said:

.  I don’t know why an American insurance company can tell you up front what you’ll pay overseas but can’t manage to do the same in the U.S.

rant over.  OP, I sympathize with you.  Dental bills suck.

They can absolutely tell us. They don’t want to because it will maintain driving the wedge between the patient and doctor. They share bits and pieces with us as private practice doctors and we have to fill in the holes ourselves.

I don’t fully understand what you mean but even I can tell this is a shady business practice.

[WOT?*]

Mar 23, 2021 2:24:35 GMT -5 sent said:

Mar 23, 2021 1:06:15 GMT -5 4speedy said:

.  I don’t know why an American insurance company can tell you up front what you’ll pay overseas but can’t manage to do the same in the U.S.

rant over.  OP, I sympathize with you.  Dental bills suck.

They can absolutely tell us. They don’t want to because it will maintain driving the wedge between the patient and doctor. They share bits and pieces with us as private practice doctors and we have to fill in the holes ourselves.

My dental providers always call the insurance company to find out the billing and they let me know what my responsibilities are. I would hope the insurance companies aren't being asshats to the providers. (although having worked for an insurance company legal department I'm sure my hopes are not the reality.)

And thank you sent for accepting state insurance. It's not always easy to find someone, especially one that takes new patients.

[Deleted]

Thank you everyone for your insight.

sent, thank you for providing a response from the side of the provider, that makes sense. The dentist is in network for my Hs insurance, and my insurance is a PPO (I think that is the term). The procedure is being billed under three different billing codes.

4speedy, I was actually wondering about that. My Dental insurance runs January to January, but Hs runs July to July, and he also has the lower coverage amount of $1500. I'm kind of hoping that when all is said and done that it does end up taking several months, because then there'll be benefits available to pay for the crown when it comes time for that.

[jlt19]

We had double insurance forever. The secondary should pay the remaining 50%, however, there may be a clause that it won't pay MORE than the primary, so it may only pay $1500.

BUT get a pre-determination. I've fought with dental insurance over them deciding not to cover something that the dentist (a "top tier" dentist according to the insurance) said was necessary. So the insurance got to magically make up their own code and ended up not even covering 1/4 of what they should have.

And I know I'm about to go back through it all again with DH because of this one stupid clause that no one knows about until it's too late. But, he needs the work even though they say he shouldn't, so WTF are we supposed to do, ya know? 

[sent]

Mar 23, 2021 2:37:49 GMT -5 4speedy said:

Mar 23, 2021 2:24:35 GMT -5 sent said:

They can absolutely tell us. They don’t want to because it will maintain driving the wedge between the patient and doctor. They share bits and pieces with us as private practice doctors and we have to fill in the holes ourselves.

I don’t fully understand what you mean but even I can tell this is a shady business practice.

Also WOT?* , yes, they are asshats, here is an easy example. 

I am in-network with Delta Dental. Most of the other insurance companies where I am in-network will give me a list of their fees so I can look at the maximum fee the insurance company will pay and calculate the 50%, 80%, etc. copays from that list. It's called a "fee schedule." However, the Delta Dental in my state will not give me a fee schedule. They have the fees available to them on their side, they just won't give them to the provider and it's shady as hell. Even if you call and ask, they won't tell you. Eventually you do figure out Delta's fees because when I send a claim, they send it back with the fee they will pay and then I see all future claims come back at that same fee. So I can start making my own little list for Delta that has code A = $50, code B = $100, etc. But I only know the fees for the codes that I frequently use which for me is braces related stuff. 

Delta has this information but won't share it with the in-network providers. I can understand not sharing it with the out of network providers since those doctors don't have a formal contractual relationship with Delta. But I signed papers with Delta saying I will honor your fees as an in-network provider and they basically said "cool, but we're not sharing those fees."

So why go in-network with Delta Dental if they play shady games? Well if I am not in-network, Delta will send their reimbursement check to the patient. Yes the office can charge the patient for that amount but this is an added layer of hassle and chasing for money owed for services provided. There are many stories of patients getting insurance checks and going on cruises and refusing to pay the doctor's office. There are laws in my state saying that the insurance companies can not do this; that if an out of network provider requests the check to come to the office they have to send it to the office. However, there is some stipulation within the law that if the insurance company is self funded or federal funded or something-something etc. that the law doesn't apply. If you ask Delta, they say "the law doesn't apply to us." I'm a dentist, not a lawyer, I don't really understand the stipulations of why the law doesn't apply. There is no good resource that I can read to understand it that is written in plain English to help me understand. 

That's just 1 story, I have so many more.