Math Problem on Reimbursement Driving Me Crazy

[Limozine]

I'm normally pretty good at math, and this may seem silly, but it's driving me crazy.

The member (in this case, my father) has an MAPD with a dental reimbursement benefit. In January he gets a routine cleaning/checkup. Total cost $149, which he pays out of pocket. He then files the claim with the carrier. The carrier accidently sends the check to the dentist. The dentist's office calls, wanting to know what to do with it. He advises them to give him a credit for the $149 toward his next cleaning/checkup.

He goes in again in July. This time, due to X-rays, etc. the total bill is $224. But the billing statement from the dentist shows a net balance of $75 owed because of the $149 credit. He pays the $75 out of pocket and files the claim himself, with a note to the carrier stating that the reimbursement should be $224 because that's the amount of the second bill excluding the credit. The carrier reimburses him the $75 and says the dentist owes the additional $149, not the carrier.

I'm having a mental block because it's clear that there were $149 + $224 = $373 in total charges, and the dentist received that amount in full, $224 from the member and $149 from the carrier. Yet the member has $149 less than he did when started, and the carrier has only paid out $224. So it would seem to me that the carrier still owes $149 to the member.

Who owes whom in this case?

 

[alphawave2k]

Assuming the entire billed amount is within the allowable limit for the time period, it seems to me the carrier (insurance company), is not following the trail too well. It's easy enough to get lost in the soup when you have this 3 way credit/pay situations. I would go back to the carrier and speak with someone that knows what they're doing...and good luck with that one....to go over the details? Based on your accounting, the company has not reimbursed the full allowable amount to either you or the dentist.
In avoidance of future snafus, I would take the reimbursement and put it in my pocket after paying the dentist, that way there's a clean-slate after every visit and procedure. Dental is such a pita, no wonder the highest suicide incidence among professionals are dentists/Dr's. Hey how come we all ain't in that group?.

 

[goillini52]

I'm normally pretty good at math, and this may seem silly, but it's driving me crazy.

The member (in this case, my father) has an MAPD with a dental reimbursement benefit. In January he gets a routine cleaning/checkup. Total cost $149, which he pays out of pocket. He then files the claim with the carrier. The carrier accidently sends the check to the dentist. The dentist's office calls, wanting to know what to do with it. He advises them to give him a credit for the $149 toward his next cleaning/checkup.

He goes in again in July. This time, due to X-rays, etc. the total bill is $224. But the billing statement from the dentist shows a net balance of $75 owed because of the $149 credit. He pays the $75 out of pocket and files the claim himself, with a note to the carrier stating that the reimbursement should be $224 because that's the amount of the second bill excluding the credit. The carrier reimburses him the $75 and says the dentist owes the additional $149, not the carrier.

I'm having a mental block because it's clear that there were $149 + $224 = $373 in total charges, and the dentist received that amount in full, $224 from the member and $149 from the carrier. Yet the member has $149 less than he did when started, and the carrier has only paid out $224. So it would seem to me that the carrier still owes $149 to the member.

Who owes whom in this case?

Just get the $149 back from the dentist.

 

[alphawave2k]

Just get the $149 back from the dentist.

Ding, ding, ding...best answer!

 

[Limozine]

Just get the $149 back from the dentist.

The dentist already issued $149 credit on the latest bill. They billed a total of $149+$224 = $373 and received a total of $149 from the member, $149 from the carrier, and another $75 from the member for total of $373. I don't see how they owe anything.

 

[LostDollar]

Ding, ding, ding...best answer!

Wrong.

 

[LostDollar]

Just get the $149 back from the dentist.

See post op just made. There is no way Dad is going to get $149 back from dentist.

 

[somarco]

This is just ONE of the reasons why I never mention dental coverage.

 

[LostDollar]

Caveat, NOT an agent. Also no knowledge of, or experience with, MAPD plans.

I think the carrier owes the money.

It sounds to me like Dad has submitted something like a statement of account rather than an actual bill for the dental services rendered, but the carrier is treating it as the actual bill for the services.

Given the way the insurance carrier has responded, I think Dad is going to have to start by getting a bill from the dentist dated with the date of service and showing the services provided and the charges for those services. Period.

He is then going to have to figure out the approach to make an appeal to the carrier about their payment and the additional amount due for the bill. I have no idea how to go about that, and how disagreeable the carrier might be in processing the appeal documents.

A very careful reading of the complete MAPD policy may show a set of steps to file an appeal for the way the carrier processed a claim. This might be a good first step which might result in the desired additional payment from the carrier.

 

[DS4]

i would personally never argue dental coverage with LostDollar as he has 3 dental plans himself.