Can a Dentist Bill an Insurance Company More Than the Cost of Services?

May 6, 2016

  1. QuestionTexas
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    QuestionTexas New Member

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    Unusual case here. My nephew went to a dentist a couple weeks ago from a crown and filling. When he left, the dentist gave him a final bill (with breakdown) for 850.00. He paid 510.00, they expected the insurance (Delta) to cover the remainder. He dentist has since submitted a bill to Delta for over 1500.00. Delta has agreed to pay a little over 400.00, but that still leaves more than 500.00 owed. Is this legal? How can they bill an insurance company more than that on the original receipt? Sounds like fraud...
     
  2. FEX Quotes
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    FEX Quotes Guru

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    Your math does not make sense..

    $850 - Final Bill
    ($510) - Paid by nephew
    _________________________
    $340 - Balance due dentist
    ($400) - Delta paid dentist
    _________________________
    $60 Over payment to dentist


    .
     
  3. QuestionTexas
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    QuestionTexas New Member

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    Sorry for the confusion. The statement he recieved from the dentist list the total cost at 850. They estimated Delta would pay around 340 (possibly more); therefore, he paid 510 out of pocket.

    However, the dentist turns around and bills delta over 1500! He (nephew) does not know where this amount, as the dentist told him the total cost was only around 850... Delta has agreed to pay 400 on the 1500 bill that the dentist submitted to them!
     
  4. goillini52
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    goillini52 MAGA...Eat More Bacon & BUILD THAT WALL!!!

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    As was pointed out to you, Delta over paid by $60. Your nephew doesn't owe any more. The dentist inflated the bill to Delta because they pay a % of the bill.
     
  5. Josh
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    Josh Retired Agent, Current List Broker

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    This is common with every healthcare provider. With dental it's more obvious, but doctors and hospitals always inflate the bill to the insurance. I think it's a hugely flawed approach, but it is normal.
     
    Josh, May 7, 2016
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  6. QuestionTexas
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    QuestionTexas New Member

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    Thanks for the replies. He's very relieved.

    One last question... He has a yearly maximum of 2500.00. Which amount will be applied? Will it be the 800, or the 1500 that the dentist billed delta?
     
  7. goillini52
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    goillini52 MAGA...Eat More Bacon & BUILD THAT WALL!!!

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    The amount paid by Delta goes toward his annual maximum benefit.
     
  8. Chrisl
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    Chrisl New Member

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    I agree, it's a flawed system and the driving factor as to why healthcare costs are so high. I started my insurance career around 20 years ago as a medical and dental claims processor. Unless the process has changed, here's how it works:

    Service is provided.

    Negotiated/contracted rate with health or dental plan for the service is: $300.

    Provider bills $1,000 for the service (only getting paid $300).

    Health/Dental plans adjust the rates they pay for services based on what is "Reasonable and Customary" in a given area.

    When it comes time to restructure negotiated rates, that $1,000 bill for that service will influence what the plan pays for that same type of service in the future. The plan will not go from paying $300 to paying $1,000, but....perhaps the plan now pays....$400 this year rather than $300 last year. And on it goes, all the while, having the rates climb and climb.
     
    Chrisl, May 16, 2016
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  9. TRUTHBETOLDSAFE
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    TRUTHBETOLDSAFE New Member

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    They can if your nephew signed a waiver. He must call the insurance company and submit a grievance with a copy of his initial bill for $850. Also, mail in a COPY OF HIS PROOF OF PAYMENT along with that same initial bill he was given to the claims address on the back of his card. Make sure he requests a delivery notice from the Post Office. During the 2nd or 3rd call mention FRAUD and be willing to be transferred to a "TIP LINE". (If he doesn't do this it will go NOWHERE!) This is why they get away with it on a rampant scale and keep doing it! your nephew should state his point clearly with no guilt or shame. Keep contesting it because it's his annual benefits are reduced. Also, find a NEW dentist!
     
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