Dental treatment through PRSI

B

brokeagain

Registered User
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226
Hi,

I have just come off the phone from my dentist secretary and I feel like screaming. I applied for Dental treatment under PRSI last year and received 2 filling caps and scaling & polish in January. I paid €60 for the caps and €45 for the scaling. I just presumed that I would get this back in my paycheck or by cheque...I didn't.

Anyway, I rang today to book in for a checkup and scaling and all was fine until I asked her if I was covered under PRSI and she replied yes. My next question for her was why I had paid €45 mins for a scaling on the last visit to which she replie snappily...look do you want a quick 10 minute scaling with the hygienest or do you want it done properly. Of course I want it done properly but isn't that what my prsi is for???? She also asked me if I really needed to see the dentist of was it just the hygienest....should she be encouraging me to get a checkup??

What are my rights here?

Frustrated and annoyed!
 
Any decent dentist would normally

  • ask you if you might be covered by PRSI in advance of performing work
  • maybe even contact SW themselves to check and to do the paperwork
  • inform you whether or not you are actually covered
  • give you some idea of the cost of the treatment being carried out net of any Treatment Benefit payments if applicable
  • perform treatments under the Treatment Benefit scheme to the same level of expertise and professionalism as those paid privately
Your dentist doesn't seem to fall into that category. I'm not sure that you have any comeback (e.g. in terms of retrospectively claiming Treatment Benefit payments) but if I was you I would make a formal complaint to the dentist and maybe even to the Dental Association and/or SW about this. I would also switch to another dentist who did not treat their clients/patients in this way.
 
Not sure exactly what is covered with PRSI but I know last two times I was to the dentist I also had to pay some money. I think only a certain percentage of the cost of some procedures are covered. My dentist has definetly advised me on occasions that I will have to pay more if I want a white filling as opposed to the grey ones because the PRSI only pays for white for some number of front teeth and grey for the rest but if your filling is going to be visible when you smile, depending on your teeth, then its better to pay the extra and get the white one. I am always presented with the claim form to sign when I go the dentist and they send off the claim but I'm pretty sure it doesnt cover the cost of everything.
 
it is the patient's responsibility to verify their entitlements and NOT the dentist and as a follow on there is NO requirement for dentist to refund for private fees charged where the PATIENT has not a white approved PRSI form in their possession at the beginning of treatment.
It is the patient's responsibility to verify their entitlement.
 
markowitzman said:
it is the patient's responsibility to verify their entitlements and NOT the dentist and as a follow on there is NO requirement for dentist to refund for private fees charged where the PATIENT has not a white approved PRSI form in their possession at the beginning of treatment.
It is the patient's responsibility to verify their entitlement.
Click to expand...
Yes - but as I said above I believe that any decent dentist will at least mention the possibility of PRSI Treatment Benefit cover to the patient if not actually assisting in checking benefit status and claiming it if applicable. I know that any dentist that I have dealt with has done this anyway. And surely no reputable dentist would suggest that those getting treatment under paid for (in part or full) by the Treatment Benefit scheme would receive a lesser service than those paying privately for the same treatment?

Details of the Treatment Benefit scheme and what's covered etc. is available from the SW website.

Treatment Benefit Scheme
 
as a dentist one has to be very careful here. it is very easy for a patient to think that they are going to a "prsi" dentist. this is exactly what the gov dept want the patient to think as they put the onus wrongly on the practitioner to establish eligibility and take the financial hit if they prove to be wrong in their assumption that the patient is eligible when in fact they are not. This is an inherent flaw with insurance based schemes which is always to the benefit of the insurance company (gov dept in this case).
And surely no reputable dentist would suggest that those getting treatment under paid for (in part or full) by the Treatment Benefit scheme would receive a lesser service than those paying privately for the same treatment?
Click to expand...
Did I suggest this Clubman?
 
markowitzman said:
as a dentist one has to be very careful here. it is very easy for a patient to think that they are going to a "prsi" dentist. this is exactly what the gov dept want the patient to think as they put the onus wrongly on the practitioner to establish eligibility and take the financial hit if they prove to be wrong in their assumption that the patient is eligible when in fact they are not. This is an inherent flaw with insurance based schemes which is always to the benefit of the insurance company (gov dept in this case).
Click to expand...
Well - all I'm saying is that in my experience with two dentists over a few decades as a patient who attended every few years (i.e. not as often as I probably should have!) was that they were quite clear about when PRSI might be an option and helpful in assisting with checking eligibility and processing applications when it was. It would not have bothered me unduly if they had told me that this was my responsibility. If I had been dealt with by either of them in the way outlined by the original poster then I would have turned around, walked out and looked for another more patient focused and reputable (in my opinion) alternative.
markowitzman said:
Did I suggest this Clubman?
Click to expand...
No - but the orginal poster did and that is what I was referring to in both of my earlier posts.
brokeagain said:
Anyway, I rang today to book in for a checkup and scaling and all was fine until I asked her if I was covered under PRSI and she replied yes. My next question for her was why I had paid €45 mins for a scaling on the last visit to which she replie snappily...look do you want a quick 10 minute scaling with the hygienest or do you want it done properly.
Click to expand...
 
we actively promote the prsi scheme for patients and have notices to that effect in our reception/waiting area as it aids patient retention when the patient knows routine scalings are free.
A receptionist is unable to tell whether one is covered or not for scaling until there is a diagnosis as to whether gum disease exists.
If this is the case a balance fee is payable which is at the discretion of the dentist. Brokeagain should enquire do they have gum disease.
The key point is not how one was "dealt with by receptionist" but rather what treatment code one was treated under.
051 Treatment of gum disease
or
030 Routine scaling.
The former attracts a balance fee.
 
Thanks for all your posts.I just want to clarify a couple of things. I was covered by PRSI on the first visit yet I was aked for €45 for scaling. It was a routine cleaning/scaling as I don't have gum disease.

I still thing I was wrongly charged the €45 as this should be free.

When I questioned this on the phone I was asked if I wanted a full scaling/cleaning or just 10 mins with the hygienest. There is obviously a difference in the trestment of a PRSI covered patient and a fee paying patient. I have been paying PRSI for the last 10 years so I feel that in effect I have well paid for my treatment.
 
To clarify some points made in this thread:

1. Quote from www.welfare.ie

"Dental Panel: The Dental Benefit Scheme is operated by dentists who have signed a contract with the Minister to operate the Scheme on behalf of the Department.
Patient Fees: Payment in respect of dental treatment will only be made when the treatment is carried out by a dentist who is a member of the Department's Panel.
The amounts payable by the claimant are available at the Dental Surgery or on request from Treatment Benefit Section. (See also Part 2. re Dental Benefit claims).
Dental Benefit may be paid in respect of dental treatment carried out in other EU member states. Claim forms and details regarding the amounts which the Department will pay towards same are available directly from Treatment Benefit Section. For services received abroad the patient pays the practitioner in full and afterwards sends the application form (completed by the dentist) to the Department. Payment is issued to the patient directly, raher than to the practitioner."
2. Procedures to claim:

"Claims

Insured persons, including Members of the Permanent Defence Forces, and their Qualified Adults can claim Treatment Benefit.
Dental Benefit:

Claims for Dental Benefit are made on behalf of the claimant by the dentist, who accepts the claimant as a patient. A claim form, D1, is submitted on behalf of the insured person and a D2 claim form is submitted on behalf of the Qualified Adult of the insured person.
Authorisation to proceed with the dental treatment may be obtained by the dentist by telephoning the Treatment Benefits Section. In this instance the dentist can proceed with the dental treatment and forward the D1/D2 form for direct payment when the course of treatment is completed.
If a claim is submitted by the dentist for written approval both the dentist and the claimant receive decision notices D3 and D4 form respectively.
If the dental treatment to be carried out is listed by the dentist on the claim forms (D1/D2) sent for written approval, the claimant is informed on the approval form (D4) of the fixed fees, if any, payable by him/her to the dentist for the various dental treatments."
 
markowitzman said:
it is the patient's responsibility to verify their entitlements and NOT the dentist and as a follow on there is NO requirement for dentist to refund for private fees charged where the PATIENT has not a white approved PRSI form in their possession at the beginning of treatment.
It is the patient's responsibility to verify their entitlement.
Click to expand...


I thought these forms were only available from dentists as they cannot be downloaded from web.
 
brokeagain said:
Thanks for all your posts.I just want to clarify a couple of things. I was covered by PRSI on the first visit yet I was aked for €45 for scaling. It was a routine cleaning/scaling as I don't have gum disease.

I still thing I was wrongly charged the €45 as this should be free.

When I questioned this on the phone I was asked if I wanted a full scaling/cleaning or just 10 mins with the hygienest. There is obviously a difference in the trestment of a PRSI covered patient and a fee paying patient. I have been paying PRSI for the last 10 years so I feel that in effect I have well paid for my treatment.
Click to expand...
As mentioned by markowitzman above it may depend on the precise nature of the treatment as to whether it's fully covered by PRSI or if the patient may be liable for some additional charge. As far as I can see the technicalities seem to be pretty complex especially to the average punter.

Most people just work on the basis that PRSI Treatment Benefit provides for a "free" annual checkup and clean/scale and covers some of the cost of some other treatments and these assumptions usually work out fine for many patients. However the specific details of what is and is not covered are more complex as far as I know and some people can get a nasty surprise when presented with an unexpected bill for what they thought was "free" treatment especially if their dentist has not communicated with them clearly on the matter.

The bottom line, as far as I know, is that the patient should:
  • Check PRSI Treatment Benefit cover status by calling SW before going to the dentist (call SW Letterkenny on LoCall 1890 400 400 (Ext 44480) and have your PPSN handy when enquiring)
  • If covered by PRSI TB mention this when initially talking to the dentist and clarify precisely what work will be done, what will be covered by PRSI and what additional charges may apply at the earliest possible opportunity.
  • Make an application for TB payment before any covered treatment is carried out. Many dentists will provide the form and maybe even sort things out once you sign it. But if not then get the form from the dentist and make the application yourself.
  • Don't forget that qualifying dental treatment not otherwise reimbursed qualifies for [broken link removed] tax relief under
  • If at any time you are in any doubt about anything regarding the treatment or cost then make sure to ASK your dentist for explanations/clarifications.
At least you'll know the next time! :)
 
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