UHC The Villages Medicare Advantage FL-004P (HMO-POS) $5000 Dental Benefit
 

According to the United document there is a $0 copay for preventive and comprehensive services like cleaning, fillings and crowns. However, I received an authorization from United that shows this for a dental crown:
Amount Claimed $1504
Amount Allowed $532
Patient Responsible $972
Amount Paid $532

I spoke with United today and am calling the dentist next. Looks like I need to pay $972.

What type of procedure was it?

I was "surprised" when I first moved here and found out that dental benefits aren't as clear as they appear to me. Now, I always get a pre-authorization before I do any dental work.

I had a crown put in a couple of years ago. I don't think the dentist did a good job as it fell off twice in the first year. (I have crown that was put in about 15 years ago and it has never fallen off.)

I went back to the dentist that put the crown in and he glued it back on for free both times. However, when it fell off a third time, I thought this might not be the best dentist so I went to another dentist who was out of network. I told him that I thought the first dentist had not done a great job so I asked about putting in a new crown instead of jus gluing the old one back on. He put it in to the insurance company and they told him that there was no coverage for putting in a second crown. I have to wait five years to put a crown in on the same tooth.

I called the insurance company and told them that I thought that their in-network doctor had not done a proper job and that I should be entitled to a new crown. She told me that no matter had bad the first crown was put on, they will not authorize a new crown until five years have gone by. I have UHC Advantage.

Yeah, UHC works until it doesn't. .
Looks like you have a different expectation/interpretation of co-pay than UHC. .
which is how they advertise, but not how they operate. .

This is for a dental crown.

You might find that as part of the Dentists agreement with UHC that the Dentist has contracted to do this work at the contracted price ie...$532.00

I know that each crown is different but I had one put on less than a year ago and it was $940.00 I did not have insurance. I now have insurance and it pays 30% of the covered charges for a crown. My guess would be if I need another one it will be about 30% higher than last year.

Correct. But seems like I am responsible for $972. I find it hard to believe that the dentist is going to accept only $532 for the crown.

I have the same plan. The website says under plan benefits:


You pay a $0 copay for all other covered comprehensive services, including crowns, fillings, root canals, extractions, general anesthesia, IV sedation, occlusal guards and modifications and adjustments to dentures and bridges from network providers

Network dentists have agreed to provide services at a negotiated rate.

I am not an insurance expert but it seems like there is no copay.

When I had the crown in 2023, the dentist billed $1378.00 and UHC paid $753. There was no coinsurance, copay, or deductible.

What did UHC say when you called?

I figured it out. The dentist needs to resubmit the estimate they coded something wrong. In network should pay 100% for the crown.

No wonder patients find billing confusing. The doctors can’t even figure it out!

Keep adding freebies to a dead horse (MA plan), it’s still a dead horse. Think about it the common sense way: the insurance company issuing the advantage plan has to make money, thousands of $$$ off of you, what are they not going to give you? Medical service for 1, they will keep denying you service until 67% of their clients roll over accept their denial of service. Don’t believe me, call them and ask them if they can deny you medical service, and then Google advantage plans being looked at in congress for shady practices

I believe your dentist may not be in-network with UHC which is the reason for the additional charge.

Out of network?

His cost is less than $100 plus time plus overhead.

That’s true with most dental insurance, not just UHC

Is he in or out of network?

They had the wrong dentist in the claim that was sent over who was out of network. The correct dentist is in-network.

I was told by a village doc that the system hires high school drop outs to code after they coded a procedure that was never done. Now, since the fraud has been exposed, it is by design. Had I not questioned the bill, it would have been paid.

I have the same plan, had 2 implants that included crowns. Since that crown was attached to an abutment UHC denied paying anything

Did you appeal???

The $5,000 is the Annual Maximum for Dental. The percentage covered for each type of service is explained in your contract or paperwork.

And here is a classic example of confirmation bias. The problem the OP had was not due to UHC denying care which should have been covered. They apparently followed the rules. The mistake was made by the dentist's office which submitted the wrong codes for it to be covered. Place the blame where it clearly belongs.

United Healthcare continues to have the worst reputation of all the crooks that run all the so-called "Healthcare services". Scum!

Is your dentist listed as an in-network dentist. If not UHC only pays a portion.
If he is listed check to see what procedure code the dentist use. A listing of codes can be googled. Wrong code have dentist resubmit. Correct code file an appeal with UHC in writing and send certified mail return receipt requested. Follow instructions carefully for the documentation required. Call their customer service afterwards every 2 months for updates.
I initially got denied a replacement on 20yr old crown on a back molar that had broken claiming it was a cosmetic procedure. Took me 10 months but got crown fully paid.

Not disagreeing, and I am guilty as well in this case. However, time wasted, and patient time wasting for sloppy work for a patient and a customer who probably wasn't the first UHC dental customer is a sign of UHCs very low reimbursement rates. . . They did start a contract renewal negotiation with coachk's hospital at less than medicare reimbursement rates. I will be interested to see the final outcome, and will concede my confirmation bias as well. .

Is your dentist in the United network? If your dentist isn’t in the United provider network, you pay the difference between the United allowable charge and what your dentist charges. If your dentist is in the network they’ve agreed to the allowable charge.

Source?
Define "his cost".
Do you know what his overhead is?
What is "fair" for his time?

Crowns placed on implant abutments are considered implant services, not general restorative. If your plan does not cover implant services, it is not unreasonable to have this type of exclusion. Some better plans might cover that, but not most.