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:

1. Has anyone successfully fought back against an HMO dentist doing this?
2. Should I report this directly to DeltaCare as a grievance or billing fraud?
3. 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.