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We just received an email from a client asking why so much of her dental bill was not covered. She stated that she had asked if the provider “took her insurance” and was assured that yes, indeed they did. Imagine her surprise when her portion of the bill was well over $400 for a cleaning and a little bit of maintenance.

This has happened so often in the past decade that we now stress that the question should be whether the office is a participating provider in a specific insurance plan. Rest assured, even though the wording of the question was not perfect, the staff person who was asked this question surely understood what was being asked.

Sadly, the staff person’s answer was correct. All providers take everyone’s insurance and will happily provide a universal bill. Participating in a plan is a very different commitment. It means that the provider has agreed to a reduced fee when seeing patients who are part of that insurance plan. When a provider does not participate there can be significant balance billing to the patient.

So what do you do when you got the right answer to the wrong question? Go back to the provider and appeal the situation. Explain to the doctor / dentist / lab / imaging center that your question was pretty universal and that you cannot imagine that this is not a question asked almost daily by other patients. Tell the person with whom you are negotiating that if you had known that this provider did not participate in your network you would have made other provisions because you had not budgeted this cost for your services. Some providers will agree readily and adjust their bill, others will stand firm on their principles and many others will agree to at least some discount.

Each situation is different and results will vary with the firmness of the stand taken by the office and the patient’s negotiating skills. Our best suggestion is to check the provider network with the insurance carrier before scheduling the appointment and then ask the provider office whether or not they participate in a particular plan. If both of these steps are taken before services are rendered and if the patient asks what the expected bill will be once the insurance discount has been applied, there is generally a lot less misunderstanding and many less dollars leave the insured’s checking account.

Think carefully how you ask this particular question the next time you need to schedule with a provider. Participating and taking are very different terms in the insurance industry. We at Czajkowski Dumpel & Associates, Inc. are happy to help you make sense of it all!