3 carriers-no one will pay

[Gari]

In May of 2000, I had some oral surgery done. I understand that part of this surgery was cosmetic and I am liable for payment on that part. But in additon to the cosmetics, I also has two quadrants of osseous surgery along with the evalutaions, anthesia and follow-up visits. As of today
2-6) between MY dental and MY health insurance AND coverage by my husband's dental insurance, a total of $333.92 has been paid to the surgeon. I am being turned over to creditors as I still have an outstanding balance of over $1600.00. Each of the carriers say they need to know more info and need to know about the other carriers........I have sent so much info to them, I could open my own dental office! Any help you can give me would be greatly appreciated. My thanks to you! FYI..I live in Dallas.

[Edited by Gari on 02-06-2001 at 03:44 PM]

 

[lawrat]

I am a law school graduate. What I offer is mere information, not to be construed as forming an attorney client relationship.


You joint all insurance companies under one lawsuit: breach of contract, bad faith breach, failure to act in good faith and fair dealing and failure to provide services. Watch them squirm. And you also contact the Insurance Commissioner and launch an investigation.

 

[Gari]

Thank you for your help. Any info I can gather is ammo for me as I have contacted an attorney.

 

[ALawyer]

I am not sure you have any real claim -- if the reason for the bulk of the work was cosmetic, that's your expense. And the largest part of the bill is probably cosmetic. I do not think there is bad faith by the insurers here.

 

[Gari]

In regards to your reply, during this 'cosmetic" procedure, I also had done at the same time, two quadrants of periodontal surgery. I am not disputing the "cosmetic" issue of this huge invoice, but each quadrant of the surgery was $750.00 plus consultation, follow-ups, etc.

Thanks for any input.

 

[JETX]

I agree. I don't believe that the insurance companies are being negligent or malicious in processing your claim.

It sounds to me that there is some great confusion over what is covered and the cosmetic portion which is not covered. As such, you pretty much brought this on yourself by not arranging for some type of separate billing or notation on the bills as to which is which.

At this point, you need to step back and review the information that you have sent to the insurance companies. Take the total bill and YOU deduct what was cosmetic, leaving just the insured balance. Send the insurance companies an accounting of your entire bill, what you believe to be un-insured and why you believe that. Then ask them to review the balance and subrogate it between the insurance companies.

Your pro-active involvement in this will probably go a long way to resolving the dilemma. After all, you really can't expect an insurance 'clerk/adjuster' to try to figure out what you already know... and for your opinions to match.

 

[lawrat]

Halket is correct to some extent. However, the general public is not usually as able (not their fault) to complete and settle such Misconceptions or Confusion by simply submitting forms. What then turns out is a bad rating on a person's credit report based on a collection for unpaid medical bills.

As such, spending alittle for an attorney now will save a lot in the future.

 

[Gari]

To clear up some confusion, I have submitted a statement several times to all insurance carriers showing the payment I have already being made for the cosmetic portion of the invoice. All I really want is the "covered" portion of the oral surgery to be paid to the oral surgeon. I seem to be going nowhere fast. (Except maybe to debtor's prison).

 

[crabmaster]

Oral surgery and insurance

I am a health insurance agent. My staff and I often get involved with claims. Since your claim is a little unusual, here are my suggestions. 1) Find out from the health/medical carrier if they cover oral surgery. Have the appropriate diagnostic/treatment code from the dentist available. Many medical insurances exclude any kind of dental, including oral surgery. If they exclude (get it in writing with a reference to the clause in the contract), you can focus on the dental carrier. 2)Make sure the dentist office is aware of the confusion. Pay the elective portion. Have them explain to you the codes used for the other charges. Ask them of their experience with your particular carrier. (these people are dealing with these claims every day. 3) with all this info, contact the dental claims person. If appropriate, get your HR person or the agent involved to be your voicepiece. Agents like me would rather help than have you complain to your boss. E-mail me if you think I can help.

 

[Gari]

Crabmaster-
Thanks for the help, I am trying to e-mail you with no luck...........I paid for the cosmetic portion of the invoice on the same day that the services were rendered. So if you could please e-mail me with any further help, I would be forever grateful to you!

 

[crabmaster]

e-mail

Gari: e-mail me @ [email protected] with the carriers involved, (yours and your wife's), size of the employer group, and any other info such as self-insured, third party administrator, other EOB's from carriers, etc.. The e-mail function in this site must not be operating.