The question of whether a dentist can charge more than the contracted amount hinges entirely on the dentist’s network status with the patient’s insurance plan. The “contracted amount,” often referred to as the Maximum Allowable Charge (MAC) or allowed amount, represents the maximum rate an insurance company agrees to pay for a specific covered service. When a dentist attempts to charge a patient the difference between their standard, higher fee and this lower contracted rate, it is known as “balance billing”. In the context of an in-network provider, the general answer is that they cannot balance bill a patient for covered services.
Understanding In-Network Contractual Obligations
The prohibition against a contracted dentist charging above the agreed-upon rate is rooted in the Provider Agreement between the dental office and the insurance carrier. When a dental practice joins a Preferred Provider Organization (PPO) network, they sign a contract agreeing to “accept assignment,” which means they accept the negotiated fee as payment in full for covered procedures. This contractual agreement protects the patient from unexpected costs stemming from the disparity between the dentist’s usual fee and the insurer’s allowed amount.
For services covered under the patient’s plan, the patient’s financial responsibility is strictly limited to the pre-determined deductible, copayment, and coinsurance amounts. If a dentist’s standard fee for a procedure is $150, but the contracted amount is $100, the in-network dentist is obligated to “write off” the $50 difference. This contractual write-off ensures the patient’s out-of-pocket costs are calculated solely based on the lower contracted rate.
The patient is protected even if the insurance plan pays only a percentage of the contracted rate. For instance, if a procedure has a $100 contracted rate and the plan covers 80%, the insurance pays $80, and the patient owes the remaining 20%, which is $20. The dentist cannot bill the patient for the initial difference between their standard fee and the $100 allowed amount. An in-network dentist who attempts to balance bill a patient for a covered service is in breach of their contract with the insurance company.
Circumstances Allowing Higher Patient Charges
While balance billing for a covered procedure is generally prohibited for in-network dentists, several defined circumstances legitimately allow a patient to be charged more than the contracted rate. One common scenario involves services explicitly excluded from the insurance plan’s coverage. The contracted rate only applies to procedures deemed “medically necessary” and listed in the plan’s benefits schedule, meaning the dentist is permitted to charge their full fee for purely cosmetic procedures or adult orthodontics if the plan excludes them.
A significant financial responsibility for the patient emerges when the annual maximum benefit is reached. Most dental insurance plans impose a yearly cap on how much the insurer will pay. Once the insurance company has paid out this maximum amount, coverage ceases for the remainder of the benefit period. For any subsequent services, the patient becomes responsible for 100% of the contracted rate, or the dentist’s full fee if the contract permits reverting to standard charges once the maximum is met.
Furthermore, a patient may be responsible for the full fee if a procedure required a pre-authorization that was either not obtained by the dental office or was denied by the insurer. A pre-authorization clarifies coverage and helps prevent surprise bills by determining the exact financial responsibility beforehand. Without this approval, the patient may be responsible for the entire cost if the insurance retroactively denies the claim.
The rules change entirely when a patient receives care from an out-of-network dentist, where balance billing is standard practice. An out-of-network provider has no contract with the insurance company and is not bound by the negotiated rate. They can charge their full, non-discounted fee, and the patient is responsible for the difference between that charge and the amount the insurer may reimburse based on a non-contracted rate.
Steps to Take When Disputing a Dental Bill
If a bill appears to reflect an improper charge, the first step is to review the Explanation of Benefits (EOB) document sent by the insurance company. The EOB is a detailed statement showing the dentist’s initial charge, the contracted allowed amount, the amount paid by the insurer, and the precise portion deemed the patient’s responsibility. Comparing this document against the bill from the dental office will reveal if the charge is for a deductible, coinsurance, or an improper balance bill.
The next step is contacting the insurance provider directly, as they are the primary enforcers of the contract with the dentist. The insurer can investigate the claim, confirm the contracted rate, and mediate with the dental office to correct the billing error. This often resolves the issue quickly, as improper balance billing is a contractual violation the insurance company takes seriously.
If the insurance company confirms the bill is incorrect, the patient should then contact the dental office, citing the specific line items and allowed amounts from the EOB. Asking the office to adjust the bill to reflect the contractual write-off is the appropriate course of action. If the dentist refuses to correct the bill and the charge remains for a covered service, the patient may need to escalate the matter by filing a complaint with the state board of dentistry or the state department of insurance.