Hello everyone,
I’m feeling incredibly frustrated and hoping to get some insight or advice from anyone who has dealt with this.
I have a DeltaCare HMO plan. I have been to two different in-network dental clinics that I assigned as my primary facilities, and both offices are pulling what feels like a massive bait-and-switch scheme to avoid honoring the plan's contracted rates.
The Crown Issue
Every office I visit gives me some arbitrary reason claiming that a porcelain/ceramic crown is "not covered" and that I have to pay out-of-pocket to "upgrade" it. However, according to DeltaCare and the physical benefits manual I received (complete with CDT codes and exact copays), these crowns are fully covered under a specific copay. By forcing these "upgrades," the offices are tacking on thousands in unnecessary out-of-pocket costs.
The Root Canal & "Uncovered" Codes
The same thing is happening with a root canal. They are intentionally adding extra, non-covered CDT codes to the treatment plan just to make me pay additional money out-of-pocket.
To put the numbers into perspective:
- I went to an out-of-network dental office just to get a second opinion out-of-pocket. Using standard, necessary codes, they quoted me around $10k, offered a $4k discount, bringing the total to $6k.
- Under my actual HMO plan, those exact same standard codes should only cost me $1.7k in total copays.
- Instead, my in-network HMO offices are adding so many "upgrades" and extra codes that they are driving my HMO total up to almost $4k.
The Prior Authorization Lie
When I questioned them, the office staff claimed they submitted a prior authorization request to DeltaCare on the exact day of my visit. However, when I log into my insurance portal, I can see they only submitted a request for the office visit code—they completely left off the requests for the crowns and the root canal.
It is incredibly frustrating that these in-network offices refuse to honor the insurance contract and are actively manipulating codes to extract more money from patients.
My questions for the group:
- Has anyone successfully fought back against an HMO dentist doing this?
- Should I report this directly to DeltaCare as a grievance or billing fraud?
- How can I find an HMO dentist who will actually just charge the exact copays listed in my manual without inventing "mandatory upgrades"?
Thanks in advance for any help.
Frustrated with DeltaCare HMO: Dental offices refusing to honor plan copays and forcing "upgrades" / uncovered codes. Any advice?
byu/Sascool93 inInsurance
Posted by Sascool93
4 Comments
Request a full pre-authorization for every code they intend to bill, INCLUDING the ones that arent covered. Some states have laws requiring the dentist to charge their in-network fees even when the codes aren’t covered, so if your state is one of them it could save you some. If they’re giving you their standard fees for the non-covered codes those would generally be much higher. That said, some states only force them to stick to the fees if the services are covered, and let them use regular fees for any non-covered procedures.
I generally recommend going to an out of network dentist if you can afford it. It is extraordinarily difficult to cover operating costs like rent and salaries for deltacare HMO offices, because the allowed fees are so INCREDIBLY low. It can result in them being biased towards over treatment, even unconsciously
You don’t need to fight back. Either they will, or won’t, do what they promised to. If you can post codes and teeth numbers, we may be able to help.
Medical practices literally hire people *specifically* to code things as high as possible to get the most money.
That’s because your plan pays so poorly for treatment that the office needs a way to make up the revenue. I’ve seen the DeltaCare fees – they would barely cover the lab bill for the crown, let alone cost of other materials, assistant wage, admin costs, etc. I’m curious as to why that office is even in network for DeltaCare.