Coordination of Benefits - Dental with Primary and Secondary

[sapper42]

What is the name of your state (only U.S. law)? Indiana

I have primary through DeltaCare which is a DMO. They operate on a fixed schedule. No percent coverage. No limits. Only co-pays. The member is only responsible for the co-pay and nothing more.

I have secondary through Wellpoint which is a typical PPO. They operate on a contracted schedule. The member is not responsible for the difference between the submitted fee and the contracted fee.

I had an oral exam which the dentist submitted to primary for $60 as "Submitted Fee".
Primary was contracted at $43. Primary paid $23. I had a $20 copay. $17 was listed as "write off".

The bill was then submitted to secondary.
Secondary was contracted at $48. Secondary paid $37. $12 was listed as "write off".

I paid $0. The two insurance companies paid a total of $60. Why?

If they are contracted at $43 and $48, shouldn't the paid amount from the insurance companies not exceed that?

The dentist claims that it is correct and that he can recoup the "write off" from primary ($17) and pass it on to secondary.

Wellpoint is unsure if it is correct or not and it pushing all the claims back to finance for reevaluation. The front line telephone operator did not believe Wellpoint should have paid more than the co-pay, but he was not entirely sure.

I am under the impression that the total insurance payments should not have exceeded $43 (The primary contracted rate). Secondary should have only paid $20 at the most. (My remaining balance after primary was billed)

While this doesn't seem like much (I listed the easiest example), it has happened multiple times throughout the year and with more expensive procedures (implants, apico, crowns). So much so, that my secondary has reached max benefits and now there are $0 remaining in my secondary plan. I've received about $200 in benefits from secondary insurance and my dentist has recouped $1800 in "write-offs". Not exactly fair since I paid $400 for secondary insurance only to get $200 in benefits.

Can the dentist pass on the primary's write off to secondary?
When combined, should the insurance companies pay more than their contracted rates?
Is there any insurance fraud taking place here?

[ecmst12]

The provider can TRY to pass on the write-off to the secondary insurance. Whether they pay it depends on how the policy is written. There is no fraud. There MAY have been a processing error. You shouldn't be responsible for anything either way (as long as your secondary insurance will pay at least your $20 copay) so you have nothing to worry about. Wellpoint will figure it out eventually. If you have a copy of the policy, read what it says about coordination of benefits.

[sapper42]

Originally Posted by ecmst12

you have nothing to worry about.

Well, I'm worried that my secondary insurance has been depleted to $0 and now I have nothing left.

There were instances where my primary picked up the tab 100% (x-ray) leaving me with nothing to pay, but the dentist's submitted fee was "magically" the max payout of both insurances combined. He got paid double what would have normally been paid out by primary. Sure, I still paid $0, but my secondary insurance reserves were being depleted.

[ecmst12]

But since you have alerted your secondary insurance to the situation, they are investigating and will take the payments back, if they were not appropriate.