Balance Billing at the Dentist: What It Is and How to Fight It

You just got your dental bill, and something doesn't add up. Your dentist's office says you owe money even though your insurance "covered" the procedure. Or maybe you're staring at an Explanation of Benefits (EOB) that lists an amount your insurance won't pay. Welcome to the confusing world of balance billing.

If this sounds frustrating, you're not alone. Balance billing is one of the most common sources of confusion in dental billing, and understanding it can save you hundreds of dollars. Let's break down what's actually happening and what you can do about it.

What Is Balance Billing?

Balance billing happens when your dentist charges more than your insurance is willing to pay, and you're left holding the bill for the difference.

Here's how it typically works: Your dentist submits a claim to your insurance for a procedure that costs, say, $500. Your insurance decides that procedure is only worth $350 to them, and they pay their share based on your plan (maybe 50% of that $350, so $175). You're responsible for your co-insurance or deductible, which might be another $175. But then your dentist says you owe an additional $150 because that's the difference between what they charged ($500) and what your insurance approved ($350).

That $150 difference is the balance billing.

When Does Balance Billing Happen?

Balance billing is most common when:

• Your dentist is out-of-network with your insurance plan
• Your dentist charges more than the "allowed amount" your insurance has negotiated with in-network providers
• Your insurance denies a procedure as medically unnecessary but your dentist still performed it (or wanted to)
• Your plan has annual maximums that get exhausted partway through the year

It's less common with in-network dentists, because they typically agree to accept what insurance pays as payment in full. But it still happens, especially when insurance denies claims.

How Insurance Decides What to Pay

To understand balance billing, you need to understand how insurance sets prices. Your insurance company maintains a list of "allowed amounts" or "reasonable and customary" fees for every dental procedure. An in-network dentist has agreed to accept these amounts.

Let's say the allowed amount for a crown is $800. If your in-network dentist charges $1,200 for that crown, they generally can't bill you for the $400 difference. That's part of their agreement with the insurance company.

But if you go to an out-of-network dentist who charges $1,200, and the allowed amount is still $800, that dentist can technically bill you for the full $400 difference (in addition to your share of the allowed amount).

What Your Insurance EOB Really Means

Your EOB can look like dental gibberish, but it tells you exactly what's happening. Here's what to look for:

• Submitted charge: What the dentist billed
• Allowed amount: What insurance will consider for payment
• Your responsibility: Your co-insurance, copay, or deductible
• Insurance pays: The amount insurance actually covers
• Patient owes: What you're on the hook for (this sometimes includes balance billing)

If the "patient owes" amount seems higher than your normal co-insurance, check whether it includes balance billing.

What You Can Do About Balance Billing

1. Check if your dentist is in-network. Start here. Call your insurance or check their website. In-network dentists usually can't balance bill you.

2. Get a written treatment plan before procedures. Ask your dentist to submit a pre-treatment estimate to your insurance and share the results with you. This shows you exactly what you'll owe before you're in the chair.

3. Call your insurance before unusual procedures. Get a pre-authorization. Ask for a written estimate of what they'll cover.

4. Review your EOB carefully. Look for the allowed amount versus submitted charge. Ask your dentist's office to explain any difference.

5. Request an itemized bill. Get an invoice that breaks down each charge separately. This helps you spot balance billing and discuss it with your dentist.

6. Negotiate with your dentist. Not all balance billing is set in stone. Some dentists will work with you, especially if you explain your financial situation. Ask if they'll accept the insurance allowed amount as full payment.

7. File an appeal if insurance denied the claim. Sometimes insurance denies procedures they should cover. A written appeal explaining medical necessity can reverse a denial.

8. Check state laws. Some states have rules limiting balance billing. Look up your state's dental board regulations.

The Bottom Line

Balance billing is legal in most cases, but it doesn't have to blindside you. The key is asking questions upfront, understanding your EOB, and being willing to have conversations with both your dentist and your insurance company.

You have more power in this situation than you might think. Dentists want to work with patients, and most will discuss fees if you ask.

Have a dental bill you don't understand? Upload it to MyBillRx and we'll break it down for free. We'll translate the confusing codes, explain what balance billing you're looking at, and suggest next steps.