Dentist bill lower than what he sent to Insurance

[CMSC]

What is the name of your state? Nebraska dentist is in Colorado


I had two dental procedure's done one on 9/19/03 and one on 10/03/03.

I had been given a pre-estimate of costs and paid my portion that I would be responsible for after insurance paid their 80%, at the appointments before procedure's were done.

I just received dental bills for procedure's done. Apparently the dentist billed me one amount and billed insurance an entirely different amount. I have NEVER had this happen.

Here is an example. On the bill is says, "Gum Graft $562" there were two done, so there is a bill for two. It says insurance is expected to pay $899.20." Leaving me a balance of about $224 or so...I paid in advance $344.60.

Now I get the explanation of benefits from insurance showing that the Gum Graft was billed to them at $800 a piece! Insurance paid their portion of the $1600 bill and left me a balance of over $900! I got billed by the dentist for that $900+.

My question is, who do I speak with about my bill being raised when it is sent to insurance? I have copies of the pre-estimate that shows exactly how much the dentist says he charges for the procedures and the amount I am responsible for. Insurance says it is between me and the dentist, dentist says it is between me and the insurance company. He is a provider under my dental plan, so I would think there is fraud being committed somewhere. I just can't get the insurance company to see that they were billed almost 2 times the amount the dentist charges for the procedure!

Is this fraud?

 

[CMSC]

Bump...


Maybe it is all too confusing. I have the claim form and it says on there that the dentist is to sign and is stating the services he submits to insurance are actual services charged. But I have the bill which shows completely different charges.

Does anyone think this is fraud?

 

[cbg]

Does your dental insurance provide a list of contracted dentists and if so, is he on it? (Like an HMO with medical insurance.) It makes a difference to my answer.

 

[CMSC]

He is a contracted provider under my dental insurance.

I have never had this happen before. Usually if my dentist (regular one, not this new guy) bills me he bills me the same amount he is sending to insurance and it will have "expected from insurance" and "expected from patient"...insurance claim submitted is the exact same amount he bills me.

This new dentist jacked the price on both of my visits. He told me one price at the visit...billed me another price later and submitted yet a different price to insurance.

 

[cbg]

If he is a contracted provider under your insurance then I have a pretty good idea what has happened.

He has put on the bill the amount that he would charge someone who was NOT with your insurance - in other words, his regular charge. By contracting with the insurance carrier he has agreed to take a lesser fee as part of the contract. He has billed you what he would normally bill instead of what his contract dictates. Depending on the exact wording of his contract with them (which neither you nor I are privy to) this may or may not be a problem - in some cases they are allowed to put their regular charge on the bill as long as they ACCEPT the amount allowed by the insurance under the contract.

For that reason, I don't see this as fraud. It may be nothing more than administrative error. However, you still should not have to pay any more than the 20% of the contracted rate (plus any applicable deductible). Contact the insurance carrier, explain that you are being "balance billed" and ask them what to do. Chances are that they will deal with it from there - if not, they will have procedures in place for you to follow.

 

[CMSC]

I don't think I am coming across very clear.

It is not that he billed me or insurance what he would normally bill. He billed me $562 a piece for two procedure's and said my amount to pay was $39. I was told by his receptionist that this $562 was what they would charge normally. This was a regular bill, then he billed insurance $800 for the same two procedures and they only covered one of them for $608.

On the insurance statement it has the dentist sign stating that the amounts he is submitting are his actual billing amounts. Well I have the bills and predetermined amounts and those are NOT the amounts he submitted to insurance.


I had the dentist on speaker when my husband was home and he said, "Your bill is different from insurance because I want them to look at this higher price and see that I may charge more than they are covering. Next year hopefully they will raise the contracted amount."

It is very confusing. But I did finally get someone at the insurance company to understand and she wants us to file a fraud report. She said if the dentists normal billing amount was $800, then that is what he should have billed me...then had insurance expecting to pay 80%. But he did not bill us that, he billed us quite a bit lower and had insurance paying less too.