How to Negotiate Insurance with your Medical Professional

Every year, my insurance allows for two free teeth cleanings. Just like everything else I pay for, I always utilize these visits. My sister recommended a new dentist because he is the husband of one of her best friends. He, at 33, owns his own practice and is trying to build a client base. I have met him before and he seemed like a nice enough fellow, so I decided to schedule a cleaning.

He is out-of-network, but for some reason, the cleanings can be out-of-network and still be completely free. I knew this before scheduling the cleaning because I called my insurance and asked.

I move cities often and always see a dentist twice a year, so I know a thing or two and let me tell ya, this guy is great. He has all the newest technology and is uniquely up-to-date on the most recent medical studies. This is the benefit of having someone who went to dental school within the decade. If your dentist went to school in the 70’s, 80’s 90’s, and honestly even the 00’s, they are probably way behind on the most recent empirical medical data.

He identified five items that needed to be done. There were three “maintenance” items and two new items. I knew this day was coming because I had been putting off fillings and such for a few years now. I told him on the spot that he was out-of-network and there was a chance I’d want all this information to use at an in-network dentist in order to maximize my insurance. He understood. However, on the way out, I asked the receptionist to share with me exactly how she would submit the five procedures. She said she would send insurance a four digit code that represents each procedure and the insurance company would do the rest.

I took that code and called my insurance. I said something like this:

“hi, I know absolutely nothing about medical insurance and I really need your advice.”

This is how I recommend opening basically any negotiation. Humility and sincerity go a long way and if you make someone feel important, you can get just about anything you desire. So I said:

The dentist gave me this code and said they would be submitting it five times to represent five procedures.

The insurance said:

1) The code represents a procedure. For that particular four digit code, insurance allows for $190 per procedure and will cover 80% of that $190. For example, if each procedure is $150, insurance will pay $120 (or 80%) and you will pay $30 (or 20%).

2) Additionally, any dollar over $190, you pay 100%. For example, if the procedure is $200, insurance will pay $152 (or $190 X 80%) and you would pay $48 (($190 x 20% = $38) + ($10 x 100% = $10))


The dentist said each procedure would be $250. So I calculated my costs:

Total Cost Submitted to Insurance = $1250 (or $250 x 5)

Insurance Code = $190 x 5 procedures x 20% (portion I pay) = $190

plus

$60 (or $250-190) x 5 procedures x 100% = $300

Total Cost to me = $490

Balance = $1250 - $490 = $760


Then, to check my calculation, I calculated the amount insurance would cover:

$190 x 5 procedures x 80% (portion insurance pays) = $760

plus

$60 (or $250-190) x 5 procedures x 0% (portion insurance pays) = $0

Total reimbursement from insurance to dentist = $760


Then I game planned. The day of the operation would go something like this: I walk in and pay $50 (my co-pay). Then, they would submit the claim to my insurance. Insurance would then send $760 to the dentist in one to three months, and I would get a bill from the dentist for $440 ($490 - $50 co-pay) to get to $1250.

Since Delta Dental thought $190 was an appropriate amount to bill for those procedures, I decided that I too would accept that amount. I started thinking about a win-win situation for the both of us and decided to name my own price but offer liquidity. So…

I called my dentist and explained my mutually beneficial plan. $250 was too much per procedure and that last $60 (the amount over $190) was very expensive since my insurance only covers up to $190 per procedure. I said:

1) Lets do $1000, so $200 per procedure, which would look like this for me:

$190 x 5 procedures x 20% = $190

$10 (or $200-190) x 5 procedures x 100% = $50

Total Costs to me = $240

and this for them

$190 x 5 (procedures) x 80% = $760

$10 (or $200-190) x 5 (procedures) x 0% = $0

Total reimbursement from insurance to dentist = $760

2) Additionally, I would pay the $1,000 upon arrival (on a credit card) instead of merely $50. Then, I would be the one waiting on the insurance reimbursement, not the small business owner. I know that insurance reimbursement takes anywhere from a few days to a few months, but since I keep an emergency fund and solid working capital (spending money), I have the flexibility to use liquid cash as a tool.


Here is how this would compare:

$250 per procedure, costing me $490

  • Dentist receives $1,250 in 1-3 months

    • Dentist receives $50 co-pay on day of procedure

    • Dentist submits for $1,200

    • Dentist receives $760 from insurance and $440 from me in the future for a total of $1,250

$200 per procedure, costing me $240

  • Dentist receives $1,000 on day of procedure

    • Dentist submits for $1,000

    • Dentist receives $0 from insurance

    • I receive $760 from insurance, costing me $240


Now, what did I say about negotiations earlier? Sincerity is key. As you can see, by the dentist coming down $250, or 20%, my bill goes from $490 to $240, a 51% decrease. Although the dollars look similar, the percentages are double for me. By the dentist merely going down 20%, I save over 50%. This was not a hard sell because it is true. I put in the time and did the research and came to a reasonable compromise. He agreed instantly. He saw the benefit to my wallet and preferred the cash upfront, so everyone won.

The five procedures went to plan and I received the reimbursement in 14 days