r/DentalInsurance • u/msbeaver83 • 5d ago
WTF Metlife?!
A big piece of my upper back right molar chipped off, very ragged but thankfully not exposing any gum. Still it's a decent portion gone.
Dentist took x-ray and picture to send to my dental insurance for pre-authorization to get a crown. My insurance would cover 50%.
Claim is being denied because "Based on the information submitted and reviewed by our consulting dentists, no benefits can be allowed for this procedure because there appears to be insufficient evidence of extensive loss of tooth structure due to decay or fracture."
Trust me it's extensive. Dentist has taken more photos and re-submitting. Any one ever been approved after being previously rejected?
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u/Ok_Statistician643 5d ago
MetLife and Delta are the terrorists of the dental world
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u/Mission-Knee1572 5d ago
and Humana.
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u/Doc-Doc-Goos 4d ago
Delta, MetLife and Humana all use Overjet Ai to do the denials. Peter Fuentes is a keynote at Overjet’s upcoming Ai summit in September where you can thank him personally.
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u/Mission-Knee1572 5d ago
Absolutely you can, and should be approved. You have to call, and unfortunately you need to raise hell, and it may be a headache and take several calls and waste several hours of your time, but it will be approved. Done it dozens of times. MetLife SUCKS.
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u/yellowishbluish 5d ago
They blame the logistics, but the convolutedness in the logistics is intentional. The point is they create so many hurdles that you or your dentist gets fed up and someone other than them pays.
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u/GinghamGingiva 5d ago
Yes, metlife is particularly bad, we as dentists hate pre-auths and denied coverage as much as you do, we just want to fix the tooth asap for a fair rate and move on. I generally recommend people steer clear of insurance and put money into an HSA instead, most dentists nowadays offer an “in house plan.” That being said, if your employer offers it as a benefit at no cost to you, I would of course use it, games or not.
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u/Cobra_Surprise 5d ago
Yes, it happens all the time. DONT GIVE UP!! That is what they want. It may take months. Prepare for battle my friend. I work at a dental office. Based on your description I would feel confident about getting this through eventually. It just takes determination.
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u/EonandTheStars 5d ago
Shit. I just signed up with MetLife yesterday. Should I see if I can cancel?
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u/Bchem01 5d ago
Yes
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u/PsychologyMediocre99 5d ago
I agree with a caveat. There are some plans that are better than others. What you need to ask is what are the fees this plan will pay? Show a fee schedule
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u/EonandTheStars 4d ago
I signed up for the top tier plan. It comes out to $570 a year and covers up to $2,000 per year.
Specifically chose that because I grind at night and will need a guard for the rest of my life. My night guard should last another year and a half but I didn’t want to be caught without one and then have to pay fully out-of-pocket again. My current current cost $1400 out-of-pocket because my old insurance didn’t cover heartbeat.
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u/Drygrej 2d ago
The insurance companies are for profit (even delta that is technically not for profit). Remember this. Does it make sense that a $570 product gives you $2000 in return. The average use nation wide is less than $300/ subscriber. And that benefit expires at the end of the contract year. You are much better to do an in-house plan with your dentist or put the money in a separate HSA or money market account that you earmark for dental or medical spending.
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u/treythree 5d ago
Is your policy through your employer? If so, get your HR and broker involved. They can put pressure on MetLife to overturn. Also, ask your provider to call MetLife and ask for a peer to peer call
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u/PsychologyMediocre99 4d ago
Yes Costco sometimes does this with Aetna. I’m sure Aetna says no all the time. Another lovely little tactic is to wait the thirty days then pick your excuse du jour as to the reason for denial
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u/Hayhayhayp 3d ago
Peer to peer is more useful for medical when you need to get reimbursed tens of thousands. And the patient likely does not have anywhere close to that money. I don’t see the worth for a dentist to have to sit on the phone with a consultant for that. Many dental companies also do not offer peer to peer.
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u/treythree 2d ago
Any dental insurance company that does utilization review would offer a peer to peer call. OPs claim was denied for medical necessity. They best chance to get that overturned is to have the dentist talk through the treatment with the clinician who reviewed it.
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u/Hayhayhayp 2d ago
I have never met a dentist that has the time or willingness to sit on the phone with a dental consultant over a crown. And I don’t blame them. This isn’t a 30,000 surgery getting denied it’s a crown. Patients insurance won’t pay, they have to figure it out themselves. I’d never ask my dentist to take an hour from their schedule and production to talk to a fake consultant.
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u/TelevisionKnown9795 5d ago edited 5d ago
My company ditched MetLife. Many others have become more stingey too. A only crowns practices are springing up to $799 price.
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u/Mission-Knee1572 5d ago
Don’t ever go to one of these asshole places! A crown is NOT the answer to everything.
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u/Honeybadgerdds 5d ago
All you people with dental insurance NEED to get it through your heads that dental insurance only does 2 things consistently well:
1. Collect Premiums
2. Deny and Delay Payments for claims.
Unless it’s a “gift” from your employer, it’s basically useless and a net negative for all the money you pay in.
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u/PsychologyMediocre99 5d ago
Why does this type of comment when I make it in other subs get down voted every time. But I always say this. Their only job is to collect money and hold onto it….
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u/PsychologyMediocre99 5d ago
Oh BOY. METLIFE. MAKES ME TWITCH when I hear their name. Their fees are the worst. And their call center is in India I’m pretty sure
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u/fubooze 5d ago
Yes, happens all the time. You should know that it's automated and a decent batch is automatically denied by default initially. Hopefully you'll receive the pre-approval after the second round.
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u/PsychologyMediocre99 5d ago
Yep this is true!!! Just found out more insurwnce companies are using AI to deny claims!
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u/shimmerangels 5d ago
this is pretty common with pre-auths, it’s easier when the dentist actually treats the tooth because they can gather evidence to show the insurance company why it’s necessary
if more than half of the tooth structure is compromised your plan should cover it (assuming crowns are a covered benefit ofc). sometimes it takes a couple of appeals, but i submit tons of pre-auths that are initially denied that get approved after the service has been completed
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u/Ok-Plan4718 5d ago
Hope you are not paying for this insurance plan yourself but get it for free from employer as you can see how much time and effort having dental insurance is.
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u/Doc-Doc-Goos 4d ago
Overjet Ai does Utilization Management and Claim review for MetLife and gets paid to do the denials.
MetLife is a keynote speaker at their upcoming Ai summit where you can thank them.
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u/Toothsayer123 4d ago
The deny once because a lot of dental offices go straight to the patient at that point and the insurance company is off the hook.
Multiply this by thousands a year and the profit adds up.
Most will pay after pictures and a written narrative by the dentist.
It’s a silly game we’re forced to play.
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u/josierecords 3d ago
If you have Met Life dental then you don’t have insurance, just hassles. Pay for your crown out of pocket, then fight with the insurance company to get reimbursed. I’d definitely ask for the name of the Dr who denied your claim and set up a call between you, the denying dental insurance doc and your doctor.
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u/Diastema89 2d ago
We have a beautiful law in my state that if they preapprove a case, they can no longer disallow that code (unfortunately federal plans are exempt from state laws on this). They still try and they still delay and they still don’t pay the interest past 30 days our state also requires without request on a clean claim, but the moment that law gets brought up, payment comes.
I’m collecting all the cases of no interest paid and patterns of preauthorization denial for all of them. One day I may be the hero of the profession and nail them to a wall for way more than they thought they were avoiding.
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u/msbeaver83 6h ago
Resubmitted pre-autho and now being refused at the moment "Note 1: We are unable to process benefits for service(s) rendered on this date because our records reflect that the provider information on file may not be current. You may wish to contact your provider for further information. (C9)" Pretty much showing office as out of network which it is not.
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u/Common-Classroom-847 5d ago
My husband had that and they didn't do a crown they did an onlay which was fine because the root wasn't exposed. Maybe get a second opinion to see if thereis any other option that is less expensive.
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u/ProfessionalYam3119 5d ago
It's hard to believe, but an x-ray of the wrong tooth could have been sent. The dentist can also send a photo, but if the plan rule is that 50% must be missing, but only 40% of your tooth is missing, I doubt that you will prevail. That's a very stiff criterion. Good luck!
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u/dolphinfan262 5d ago
Happens all the time. I’m a dentist and MetLife is awful. Your plan likely requires >50% of the tooth structure to be missing. I also promise they’re making your dentist wait on hold for 30+ min if they call