Can your dentist charge more than allowed by the contracted amount shown on the Explanation of Benefits (EOB) issued by your insurance? It depends.
The allowed amount is a lower wholesale rate negotiated by the issuing company, providing a significant discount compared to most submitted retail fees.
In-network dentists signed a legal agreement requiring these discounts for covered services; out-of-network providers did not.
Dentists charging you and your insurance is not illegal. Balance billing for deductibles, co-payments, and out-of-network fees is legitimate.
When dentists overcharge on the contracted amount, loopholes in fee capping laws make it possible to dispute the higher bills.
More than EOB Amount
Dentists can sometimes charge more than insurance allows. Other times, they must adhere to the contract amount stated in the Explanation of Benefits (EOB).
In Network
In-network dentists must accept what insurance allows, as stated on the EOB, as full payment for covered services. However, they can often charge above that figure when the plan does not make payment.
State fee-capping laws vary, which may help or hurt you when filing a billing dispute for uncovered services. Read more about the topic in the final section.
Waiting Period
In-network dentists can often bill more than the contracted amount when the waiting period exclusion means the treatment is not covered. A waiting period is a time before benefits begin for specified services.
Dental insurance with no waiting periods frees patients to circumvent this billing loophole. Although the percentage paid is lower during the early years, the cap on fees for covered services offers hidden value.
Annual Maximum
In-network dentists can often bill above the contracted amount when the annual maximum means part of the treatment is not covered. A yearly maximum limits what your plan will pay in twelve months.
One way to get around the annual maximum is to spread treatment over two or three years instead of consolidating services into one. This method doubles or triples the negotiated discounts.
Excluded Services
In-network dentists can often bill more than the contracted amount when the dental plan enacts a pre-existing condition exclusion. A pre-existing condition means something previously diagnosed before the coverage began.
For instance, a missing tooth exclusion means that your insurance will not cover replacement options such as implants or dentures if a dentist extracted your teeth before the policy’s effective date.
Frequency Limit
In-network dentists can often bill more than the contracted amount when the frequency limit means the plan will not cover a specific treatment. A frequency limit restricts the times it pays for specified services over a defined period.
For example, periodontal treatment costs with insurance might be higher than expected if you need root planing and scaling (deep cleaning) more often than your plan permits in a year.
Out-of-Network
Out-of-network dentists can charge whatever they want for all services because they do not have a contract with your insurance company holding them to the allowed amount stated in the EOB. The office did not reach a binding legal agreement to “accept” that figure as full payment.
Provider Directory
Because out-of-network dentists can charge whatever they want for all services, you should find a participating provider before starting treatment. Fortunately, insurance companies make it easy.
Use their online provider directory to find an office participating in your plan (accepting the allowed amount as full payment for covered services).
Didn’t Tell
“My dentist didn’t tell me they were out-of-network” is not a valid excuse in a billing dispute. You may be responsible for fees above the contracted amount specified on the EOB.
It is the patient’s responsibility to understand their insurance plan, not the dentist’s. Be sure to ask the right questions before starting treatment.
- Accepting means they will gladly cash the benefit check paid by the insurance company and then bill you for the remaining balance without discounting their prices.
- Participating in-network with your insurance means they will discount their prices for covered services to the allowed amount and will only balance bill the cost-sharing components: deductible, co-payment, coinsurance, etc.
Plan Design
While in-network dentists cannot charge more than insurance allows, as stated in the EOB, this rule applies to Preferred Provider Organizations (PPO) and Exclusive Provider Organizations (EPO). Not every dental plan works the same.
Instead, the industry markets a wide array of designs that do not always include a contracted amount.
- Table of Allowance (Supplemental) designs pay a set amount per procedure independent of the dentist’s fee schedule.
- Indemnity (traditional) plans reimburse a percentage based on the Usual Customary Fee (UCF) for a local area.
- Health Maintenance Organizations (DHMO) prepay dentists to treat member patients at no further cost or a minimal fee.
- Direct reimbursement pays a percentage of fees for covered services.
You and Your Insurance
Your dentist can charge you and your insurance a portion of the allowed amount or above it. Do not be alarmed. Split billing is a standard industry practice and not a cause for alarm or a sign of an illegal act in many cases.
Cost Sharing
In-network dentists frequently charge you and your insurance because most plans include cost-sharing components. In these instances, we refer to the portion of the allowed amount listed as the patient’s responsibility on the EOB.
Annual Deductible
In-network dentists can charge you and your insurance the allowed amount when you have not met your annual deductible. A deductible is an amount you pay before benefits kick in each year.
Co-payment
In-network dentists often charge you and your insurance a percentage of the allowed amount specified by the co-payment. A co-payment (or coinsurance) means the patient and the plan share in the cost of a covered service.
For example, your plan’s co-payments or coinsurance might follow this model.
| Service | Plan Pays | Patient Owes |
|---|---|---|
| Preventive | 100% | 0% |
| Basic | 80% | 20% |
| Major | 50% | 50% |
Balance Billing
Out-of-network dentists frequently charge you and your insurance through a process known as balance billing. In this case, balance billing means the difference between the submitted fee and the allowed amount.
The submitted amount versus what your plan accepts is often enormous, sometimes twice as high. With shockingly high fees, balance bills from out-of-network providers can be challenging to afford.
Avoid expensive balance billing scenarios by verifying network participation with your plan before starting expensive treatment.
Disputing Overcharges
Patients should learn what to do when an in-network dentist overcharges them relative to what insurance allows. State laws relating to non-covered services are tricky, but loopholes provide a basis for legal disputes.
Fee-capping laws permit in-network dentists to bill whatever they want for non-covered services (see above for details). These rules apply only to plans sold in that state that are not self-funded, creating two loopholes you must understand before filing a dispute.
Self-Funded
If your dentist overcharged you relative to what insurance allows, the first thing to do is investigate whether your PPO or EPO plan is self-funded. Fee capping laws apply only to fully insured plans.
Contact the human resources department and ask if the plan is self-funded, which frequently occurs with larger employers. Self-funded plans do not have to comply with state fee-capping laws.
Your cost of dental implants with insurance could be significantly lower if your plan is self-funded. Your prosthodontist must extend the discounted contract rate above the annual benefit maximum, a frequent occurrence with this expensive procedure.
Issue State
Investigating which state your PPO or EPO dental plan was issued in is the second thing to do if your dentist overcharged you relative to what insurance allows. Fee-capping laws apply only to plans sold in the state.
The rule interpretations vary based on whether you have individual or group coverage.
Individual Plans
Patients can purchase individual dental insurance outside of their employer, and when doing so, the fee-capping laws are straightforward. Apply the rule in your state.
Only ten states do not have fee-capping laws permitting dentists to charge more than insurance allows for covered services. If you live in one of the forty other states, you have no legal basis for a dispute.
| Arizona | Delaware | Indiana |
| Maine | Massachusetts | Michigan |
| New York | Ohio | South Carolina |
| Vermont |
The cost of dentures with extractions with insurance should be much lower for people purchasing individual plans in these states, as the discounted rates must extend above the annual maximum.
Group Plans
If you obtained dental insurance at work, it might be a group plan sold in one state but covering employees nationwide. In these cases, the fee-capping law in the issuing state prevails.
For example, employers headquartered in New York might purchase a plan sold there, and dentists would be prohibited from charging whatever they want for non-covered services.
