Billed after payments made at time of service

[November Rain]

What is the name of your state? CALIFORNIA

My dentist states I owe him $114.00. Each and every time I had something done, I paid my portion in full. The remainder would be paid by my Insurance Co (Blue Cross).

All of a sudden, the dentist states I owe him the above amount because the Ins. Co. only paid a portion of the remaining amount, which left the balance.

Q: Am I liable for the unpaid portion of those bills? Under what Law/ Code, Section?

Q: What recourse do I have?


Q: If I don't owe that amount, how (in a letter) should I respond to this Statement from the Dentist

OR

Q: If I do owe this amount due to the lack of payment on the part of the insurance co, how (in a letter) should I state to them to get the fire lit under their rears??

Thank you in advance for your assistance.

 

[cbg]

I doubt you will find any law that specifically states, when your insurance only pays a portion of the bill, you do/don't owe the balance. However, in the absence of a law saying that you DON'T owe the difference, you DO. So yes, you are responsible for paying any portion that the insurance does not. NOTHING in the law says that if you have insurance, you do not have to pay for services rendered regardless of what the insurance does.

The ONLY exception to this would be if your insurance is a managed care plan of some kind (unlikely for dental insurance, but not impossible) where the doctor has agreed to accept x amount as full payment. IF that is the case, then your insurance carrier will be able to help you with this, as it is their contract with the dentist that is being violated.

A good way to tell would be to look at the Explanation of Benefits you received from the insurance company when they made their payment. If it says, "Patient Pays X amount" then you owe that amount. If it says, "Patient Pays $0.00" then you don't owe anything. If that is the case, contact the Provider Relations department of your insurance carrier for help.

 

[krispenstpeter]

Am I liable for the unpaid portion of those bills? Under what Law/ Code, Section?

Under the law of contracts.

What recourse do I have?

Pay the bill.

If I don't owe that amount, how (in a letter) should I respond to this Statement from the Dentist

You don't respond except to pay the bill. Any correspondence is between you and your insurance carrier.

If I do owe this amount due to the lack of payment on the part of the insurance co, how (in a letter) should I state to them to get the fire lit under their rears??

You do as Blondie suggested and read your policy.

 

[cbg]

Hey, krisp, I'm not blonde....

 

[krispenstpeter]

You are in my fantasy

 

[cbg]

!

 

[lkc15507]

November Rain:

First, as all the others have said, read your coverage booklet. It seems you may be assuming that services are covered when in fact they are not. The fact that you have paid your portion according to the provider, may or may not be correct. The provider may or may not understand the benefits of your particular plan. You are ultimately responsible for all unpaid amounts to the provider. Depending upon the type of service received, your insurer will likely reimburse a different percentage of each type of service rendered (for example: cleaning vs. a crown--typical percentages would be 80-100% vs approx. 50% respectively). Also, any deductibles would have to be considered.

If after reading your coverage, you still feel your claims paid in error, then 1.) notify the provider in writing that you are filing an appeal and 2.) file the appeal with the insurer. The provider does not have to wait for your appeal, they can attempt to collect from you. Therefore, pay attention to any attempts of collection that the provider sends to you. Address all of them in writing. Next, thoroughly research and appeal the claims payment based on coverage issues outlined by your plan booklet from the insurer. I don't mean to be cruel, but "I thought", "I want", "I deserve", "I need", statements just don't carry much weight. Look at the booklet, base your appeal upon what the booklet says your coverage is / should be.

Sincerely,
lkc15507