Be familiar with what your insurance covers, and make sure your doctor is, too

by Karen on September 15, 2008

About a month ago, my husband and I both went to the dentist for routine exams and cleanings. Because we’d been uninsured for a year, it was our first visit in about that long. It was also our first visit to a new dentist, so they did a full round of x-rays in addition to the cleaning and exam.

No cavities or problems for either of us (woo hoo!), and routine preventative care is fully covered by my insurance, so we left that day with no bill. Or so we thought.

Two weeks later, I received a statement of benefits that said we’d been denied coverage for $14 of each of our claims.

When I called to ask about it, I was informed that my dentist took three of a certain type of x-ray. My insurance only covers two within a 12-month period. My dentist hadn’t checked to see what was covered, and I didn’t know, so I let them take the x-ray that may or may not have been necessary. Because x-rays are considered “preventative care,” extra ones are not even covered by the 80/20 part of my policy. For preventative care, it’s all or nothing. We’re responsible for 100% of any preventative care that isn’t covered.

Luckily, it was only a $14 x-ray. So our total out of pocket for both of us will be $28. Without insurance, we would have paid over $500 for our exams, cleanings, and x-rays. If you ask me, $28 for healthy smiles is a bargain.

This experience made me think, though: what if the uncovered procedure had been something more expensive? I had no idea what my insurance actually covered as “preventative care.”

I assumed that my entire visit would be considered “preventative care,” but I didn’t know enough about my policy to ask my dentist questions. I certainly didn’t know enough to say, “My insurance only covers two x-rays, so if the third isn’t absolutely necessary, I’d really rather skip it.” I don’t know if dentists take kindly to this kind of request, but I’d be comfortable asking if I had known it was necessary.

We already made appointments for our second cleanings and exams of the year six months from now, so I decided to check with my insurance company to make sure it will be covered. I didn’t want to be stuck with 100% of the cost of our second cleanings/exams if my insurance only covers one cleaning for each of us per year. Turns out we’re each allowed two cleanings and exams per year, so we’re fine.

What did I learn from this? Though I’ve always checked my insurance policies for general information (i.e. do they cover 100% for preventative care? What percentage of other procedures and prescriptions will they cover?), it’s also important to look at the minute details that I might otherwise ignore, such as exactly how many x-rays they cover and what’s considered “preventative care.”

Not only did I not know that my insurance only covered two of that particular type of x-ray, I had no idea that they were taking three of them. In the future, I’ll be prepared when I show up for doctor or dentist appointments. I’m going to become familiar with the little details of my policy, and I’ll begin the appointment by politely requesting to be informed of each procedure they’re going to perform. If I’m educated about what they’re doing, what’s covered by my insurance and what’s not, I’ll be able to make educated decisions about whether I want to go through with the procedures or not.

Obviously, if the doctor deems the procedure medically necessary or if it’s an emergency, then I won’t be crunching numbers in my head. Our health comes before money. But if it’s just an extra x-ray and the doctor says there’s no harm in skipping it, I might want to pass.

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Avoiding unnecessary medical procedures that aren’t covered by insurance | Frugal Living Tips & Money Saving Ideas | Living Well on Less
January 17, 2009 at 4:38 pm

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