Dental Fraud

[Zigner]

I’ll check with insurance company today. Problem is he never filed a claim with the insurance company. I thought he was filing at the end of the service, but only received 1 for another unrelated to the bridge. I was paying him on the installment plan, giving him $2,000 payments, til the Novacain and NOx incidents.

That is different than you originally explained. Your original explanation was that he was collecting payment from the insurance company and then billing you for the remaining balance. I would suggest that you start filing the claims with your insurance company, who should then pay you directly.

 

[dabelms]

It is your responsibility to make sure that your doctor is in-network. While the doctor may accept payment from your insurance provider it does not mean that he is in-network and has accepted their cost structure.

I did get 1 bill for the cap he made and it showed a write-off and amount I owed, so I never gave it a thought that he wasn’t going to do anything different and certainly did not think he wasn’t going to Bill my ins at all fir the major work. That was a definite surprise and lesson earned. I went to him previously 19 years ago fir 2 cavities and he did 4. I was impressed..less time in chair and no future visit

 

[PayrollHRGuy]

None of that changes the fact that you need to confirm that the doctor is in-network and accepts the insurance price caps.

 

[dabelms]

That is different than you originally explained. Your original explanation was that he was collecting payment from the insurance company and then billing you for the remaining balance. I would suggest that you start filing the claims with your insurance company, who should then pay you directly.

Sorry if I wasn’t clear. He never billed the insurance company for any of the work for the bridge. I did not know that until I went to the new dentist and he assumed the other dentist did it was going to and I had to pay him cash. I called the insurance company and they verified he did not submit the claim. The only claim they had on file was for the cap. I received the reconciliation invoice for that and paid him what I owed.

 

[Zigner]

Sorry if I wasn’t clear. He never billed the insurance company for any of the work for the bridge. I did not know that until I went to the new dentist and he assumed the other dentist did it was going to and I had to pay him cash. I called the insurance company and they verified he did not submit the claim. The only claim they had on file was for the cap. I received the reconciliation invoice for that and paid him what I owed.

Then you should file your own claim. Contact your insurance company for assistance.

 

[cbg]

I am going to make one, and only one, attempt at this.

"Dr. X accepts ABC insurance" and "Dr. X is a participating provider with ABC insurance" do not mean the same thing. All participating providers accept the insurance; not all doctors who accept the insurance are participating providers.

A participating provider has signed a contract with ABC insurance to bill you only within the limits of the insurance policy. A non-participating provider has not signed any such contract and is not bound to honor the insurance policy limits EVEN IF THEY TELL YOU THAT THEY ACCEPT THE INSURANCE.

A participating provider cannot bill you for balances beyond the policy limits. A non-participating provider can, even if they "accept the insurance".

Sounds to me as if your dentist is a non-participating provider.