Dental Insurance Question - Help! - Insurance News Magazine

I am so confused and frustrated with Aetna about a recent dental claim

TLDR; Got Invisalign, paid estimated patient share up front, Aetna denied the claim AND said my owed share was $0. Dentist doesn’t want to refund, Aetna giving runaround to all of us with conflicting info to both me & dental office. Now dentist wants to bill me full amount even though EOB says they can’t.

In Colorado

Long story — I started a new dental DMO plan through Aetna in Feb 2024, specifically because it had a good orthodontia plan. I found a new in-network dentist to do a regular cleaning, and I asked them about Invisalign at my first appointment. The dental office called Aetna and got an estimate worked up, for ~$6100. Because Aetna was estimated to cover 50% of the orthodontia, as per my DMO plan, I was billed $3350 (there was a charge for a post-treatment retainer too, so my billed amount was slightly over 50%). Got my molds done in March, aligners were received by dental office in late April, and I started my treatment in late April.

I paid the $3350 upfront based on the estimate, same day as tooth molds. Aetna DENIED the claim (which was for $8120, not the originally estimated $6100), with my EOB stating “You do not have to pay this. This dentist is not contracted to provide this service for DMO/DNO members.” I was upset, but then I saw on my Explanation of Benefits that MY SHARE was $0. But Aetna was ALSO paying $0. I called Aetna and asked for clarification, and they said I should not have been billed for the service, because the dentist wasn’t contracted with Aetna to perform orthodontia (apparently I should’ve gone to a specialist/orthodontist, which was never stated anywhere).

See also PPO 500 and PPO 2000???

Well, I WAS billed for the service, and I paid my estimated share already. After numerous confusing phone calls and a physical mailed-in inquiry to Aetna**, I finally got on a 3-way call with an Aetna rep and the dental office manager. The rep told the dental office that I shouldn’t have been billed, and they owed me a refund. Dentist agreed to look into my account further, and we all hung up.

**(side note on the mailed-in inquiry, I sent all my documents including estimate and payment receipt, and asked for clarification because how could Aetna pay $0 and also tell me I owe $0, and they responded with a letter saying they were figuring it out and would get back to me in writing. When I called a month later, they said the case had been closed! No resolution!)

After hearing nothing for a couple weeks regarding a refund, I called the dental office again. They said they spoke to Aetna supervisors today, and that actually I, the patient, should be on the hook for the full $8120 because the dentist wasn’t contracted with Aetna to perform Invisalign. They said Aetna will be mailing me something to explain this, EVEN THOUGH my EOB says my share is $0 (and a rep also confirmed the EOB sent TO the dental office stated that “therefore the member cannot be billed”). They also said there was a problem because my insurance ended at the end of April, before I physically received the aligners, which just blatantly isn’t true. I had coverage through July but just switched to COBRA when I lost my job. There was no lapse in coverage whatsoever.

I am livid at how long and frustrating this process has been. I’m mad at Aetna for closing my case without providing a written resolution, and for giving totally inaccurate or misleading info to either/both me and the dental office over the past 6 months!

Does anyone know what I should do next? I plan to call Aetna once again, but it’s a total crapshoot as to how helpful the rep will be. It will be my 10+ call over the past two months, with different reps giving all different info. Do I ask for a supervisor and stomp my feet until I can get a real answer (and maybe get on a 3-way call with dental office)? Do I reach out to some external official (ombudsman, attorney general, idk??)? Does the dentist have any obligation to abide by the EOB from Aetna?

For clarification: this dentist was IN NETWORK with my DMO (and the regular cleaning was fully covered as expected). The dental office is cooperating as far as I can tell, but they are also trying to get clarification because it’s reasonable that they don’t want to be doing Invisalign for free/eating the cost themselves. Aetna is just giving us all conflicting info and I am stuck. I also moved out of state so I can’t just go into the dental office. SOS.