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Does a participating Aetna PPOPDN dentist have the right to receive payments from the patient that exceed the insurance copay Aetna has assigned to a service?
Salsy46
Your dentist should only be charging you the difference between the Aetna allowed fee for the exact service you are getting and the amount that aetna pays to him. The reason I say exact service is because sometimes the insurance companies do what's called downcode, which is basically paying on a code that is similar to what you are having done but the charge is lower. You would still be charged by the dentist the more expensive fee and have to pay the difference. For example if you were getting a tooth colored filling (1 suface): 1 surface filling: (Normal Dr.'s Fee) =$225 1 surface composite: Aetna Fee (not true amounts) =$100 Insurance says they will pay as if it were the silver= 80% of $30= $24 Your total copay =$76. Even though the insurance company only considered that they would pay for a silver filling, y ou are responsible for the dif between the true service and their portion. Your doctor can not still charge you the $225
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∙ 15y ago
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