- October 25, 2023
- Posted by: legaleseblogger
- Category: Related News
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The AI Legalese Decoder can provide assistance in understanding your rights and options in this dental billing issue. By analyzing your situation, it can help you navigate potential legal implications and suggest courses of action.
**Background and Insurance Payment Issues:**
In a previous post, I shared my concerns regarding my dentist’s failure to bill my insurance appropriately, which led to a delay of almost three months. Luckily, I was able to resolve this issue, and my insurance company eventually received the necessary documents. Consequently, an explanation of benefits (EOB) was provided, revealing crucial details such as the submitted amount, approved amount, allowed amount, and coverage percentage.
According to the EOB, the dentist submitted approximately $250 of charges to my insurance. However, the approved and allowed amount was only $110. Thankfully, my coverage percentage was 100%, resulting in network savings of $140. My insurance company ultimately paid $110. Despite this, I was perplexed when I received a bill from the dentist amounting to $140.
**Confirmation from Insurance Provider and Unresponsive Billing Department:**
To rectify the confusion, I engaged in a conversation with a customer service representative from my insurance company. They validated that the dentist is indeed within the network and should be responsible for waiving the difference between the submitted amount and the approved/allowed amount, which totals $140. Furthermore, I possess several recorded calls with my dental billing department, corroborating my insurance company’s network status. However, the dental billing department has recently become unresponsive, failing to answer my calls or return any messages.
Unfortunately, the bill I received from the dentist only states, “insurance paid $110, balance due from patient $140.” This situation has instilled growing apprehension within me, as I fear the possibility of the dentist resorting to debt collection tactics. Consequently, I am uncertain about the appropriate steps to take, particularly if the dental office continues to evade communication. I am located in New Jersey.
**Leveraging AI Legalese Decoder to Understand Options:**
Given the circumstances, especially considering the worst-case scenario where the dental office completely avoids any communication, I am seeking advice on my available options. With concerns about potential repercussions, such as the bill being sent to collections, I am growing increasingly anxious. It appears as though the dental office is incorrectly billing me as if my insurance company is out of network, despite their actual in-network status. Due to the complexity of this matter, I am considering reaching out to a legal advice subreddit for further guidance. However, before doing so, I am hoping to leverage the AI Legalese Decoder to better comprehend my rights and explore the best courses of action in this situation.
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Does your EOB show the patient portion is $0?
DonÔÇÖt call them, leave a paper trail. Send over your EOB from insurance company, along with a letter stating that your dentist have been paid in full, you donÔÇÖt owe them the $140. Send it certified with return receipt. Keep a copy of everything.
This is balance billing and is illegal in some places, call them and ask if this is balance billing, once they know you know then they tend to drop it because if they push it and itÔÇÖs illegal where you are they get in trouble which can include fines and even other regulatory punishments (as severe as the dentist losing their license to practice).
>What are my options, particularly assuming worst case scenario that the dental office completely ghosts me?
Get the insurance company to help you and have them call the dentist. They don’t want their network docs screwing around.
>It seems to me like they are billing me as if my insurance company as out of network, even though they are in network.
They are stupid. Or greedy. Or both.
This exact situation happened to me.
Have all communications in writing. After a few exchanges of the admin saying that they couldnÔÇÖt show me additional documentation of the charges they claimed I owed, I began CCing the dentist himself. In my instance, the name of the practice was his name – so reiterating the name instead of ÔÇ£youÔÇØ was a plus (reputation-wise).
I was able to tell the dentist what insurance told me A) the dentist submitted XYZ services on these dates for this amount B) insurance paid X amount on this date C) your patient responsibility is X. I kept some information to mention later to dispute their claims. For example, IÔÇÖd say that insurance said theyÔÇÖve paid their portion, in a later email I explicitly mentioned dates and amounts.
If possible, have correspondence with your insurance company via chat on their website. I was given a copy of the transcript to then provide to the dentist.
I fought with this dentist for 5 months (albeit a larger dollar amount). Be relentless, this is fraud.
Orchestrate a conference call with the insurance company calling the office direct with you on the line. The office has a lot to lose and can be opening themselves up to an audit by the insurance company. I’m also a huge believer in paper trails. Email a complaint to the office including a copy of the eob stating that this seems like improper billing and copy the letter to the state dental board. Also don’t assume that the dentist is aware of this billing issue even though ultimately responsible. Front desk clerks are not always trained properly and dentists aren’t always as engaged in the business part as they should be. (Dental office manager for twenty five years here)
I had this exact situation happen to me as well. In my case, my insurance told me to let them handle it. A few days later I got a corrected bill showing no balance.
If they are charging you the difference between the amount allowed by your insurance and what they charged, thatÔÇÖs called balance billing. Call your insurance company and let them know, they will handle it. Your insurance company has a contract with them and it includes rates, if they are trying to charge more they arenÔÇÖt honoring the contract.
If you owe zero due to in-network negotiated rates then your insurance should be sending a fu letter to your dentist about it. Make sure you report the dentist and their billing office… They are probably doing this to a ton of customers.
I donÔÇÖt suppose this is a dentist in East Brunswick, NJ?
I had the same issue where we actually submitted a pre authorization in which it said that the service was covered and I would have to pay 0.
Dentist refused to listen to me and said unless you prepay, we wonÔÇÖt perform the services.
IÔÇÖve since moved onto another dentist.
Before you file a complaint, give them your EOB and let them know youÔÇÖll file. TheyÔÇÖll straighten up.
File a complaint with the NJ department of health (https://www.nj.gov/health/guide/file-a-complaint/#3) and contact your state representative. This is what I did to resolve a physicians offices messed up billing practices and yeah, this is messed up. Theyre contracted for an amount in network with your insurance. You dont pay the difference.
Balance billing is illegal. Look up the No Surprises Act. You can tell them to take it up with your insurance or to kindly shut up.
This happened to me with a physical therapist for my leg. When I called my insurance I told them what happened then asked them to verify the therapist office had signed a contract with the insurance saying the therapist accepted the insurance payment amount was full payment of the debt. The insurance then said, yes, the contract with the therapist did say that and went on to say they would call the therapist office and take care of the matter. The next week the therapist office called me to say my bill was paid in full. YMMV
Are you absolutely certain the dentist is in network? Perhaps they had dropped out and there is confusion with that. I have heard stories of insurance companies making life really hard for dentists who drop out of network by telling their patients (incorrectly) the provider is still in network when they in fact, arenÔÇÖt. If they are in network, you donÔÇÖt owe that. The dental office and insurance co should be able to verify one way or another. If they are out of network, you do.
Time to stop communicating verbally and go old school. You need paper.
Start with a letter to the dentist in traditional business letter format:
AllThingsAGoTÔÇï
${your streat address}
${city}, ${state} ${ZIP code}
${Dentist’s name}
${Dentist’s street address}
${city}, ${state} ${ZIP code}
25 October 2023
Dear ${Dentist’s name}:
This pertains to the services rendered on ${list dates here}.
It is my understanding, and has been confirmed by both you and ${insurance company} that you are an in-network provider for them.
Enclosed, please find a cop of the Explanation of Benefits (EOB) that I have received from ${insurance company} pertaining to that date, along with a copy of a bill I have received from your office that appears to be in conflict with it. In particular, please take note of the patient’s obligation section of the EOB.. I have made a payment in this amount on ${date you paid} using ${means of payment}. I have enclosed a redacted credit card statement to demonstrate this fact as well.
A copy of this letter, along with all of the enclosed documents will be forwarded to ${insurance company} for their consideration as well.
It is my expectation that this matter is now closed, and that no further attempts will be made to collect.
Sincerely,
AllThingsAGoTÔÇï
Patient
xc: ${insurance company}
enc: EOB from ${insurance company}
enc: Account statement showing outstanding balance different from EOB
enc: Proof of payment of my obligation
So you send that to your dentist, then you send another copy to the insurance, in which you can optionally add another cover letter explaining the situation to them.
WhatÔÇÖs sad is a lot of people will just pay this bill and never hear or think about it again.
Write them a letter disputing the bill. In the letter let them know that they can not further bill you due to them being in network for your insurance. Then add a line at the end stating if they demand further payment you will pursue a lawsuit against them for damages for violations of the Fair Debt Collection Practices Act FDCPA)
I would also file a complaint with the insurance company as this isn’t what they negotiated with the dentist office. Maybe they’ll let you do a three way call and have a conversation with all parties on the line
The dentist does not act according to their agreement with your insurance. You owe them nothing more than what they were paid through your insurance since they are in network. Remind them of that and if they insist report them to your insurance company.
Balance billing is illegal in some states, so check your state. Feel free to write your state attorney general’s office, either way.
Balance billing is against the law in NJ. In network provider agrees to accept payment by the insurance carrier at the agreed upon rate. Tell them to kick rocks.
This is typical with dentists. When I got an “upgraded” crown, I had to sign a form stating I will pay the remaining balance not covered by insurance. Because they only have 1 code for crown that takes a week to make, and if you want the same-day, 3D printed crown, insurance might cover, say up to $500, but the upgraded crown cost $1200, you’re on the hook for $700.
Did you sign any form like that? If so, you’re on the hook. Otherwise they should not be balance billing you.
You have a zero balance. The office must write off the difference if they are in network.
If your dentist has a billing department then your going to the wrong dentist.
Have you called the dental office? It could just be a mistake.
You need to build a paper trail, mostly likely this will go to collections. Doing a few things now will make this easy to handle. Take photocopies of everything (the bill, the insurance explanation of benefits, and document the date, time and who you spoke with at the insurance company that confirmed the in network authorization) send these with a cover letter explaining everything as you have here. Keep a copy of everything for yourself, and mail it to the dentist office with a “return receipt requested” from the post office. That should resolve it, but knowing billing departments (i used to work in one) it probably will still go to collections. The billing system just dumps everything in status “unpaid and insurance not pending” after a certain date (usually 120 days), it is not like someone is is looking and choosing who get sent to collection and who does not. It is just an online data dump.
If it does go to a collection agency, as soon as you get the first notice you have 30 days to dispute, but you MUST do so IN WRITING. send copies of everything you sent to the dentist and add another cover letter stating you dispute this balance, it is not a valid debt, and to please review the enclosed documentation. Keep a copy of everything to sent to the collection agency, and mail it with a return receipt requested.
Phone calls are he said-she said, saying you wrote a letter is useless, they will claim they never received any letter and by implication you never really sent one. You have to have proof that the letter was received. If by a small chance this end up on you credit report having all this documentation will allow the credit reporting agency to remove it. That is why you take these simple steps now, and it saves you a ton of grief later, not to mention your credit score.
every dentist i have been to (NC) asks me to sign a form saying i will pay the balance of what they charge and what insurance pays.
Can you post your EOB and blank out identifying information. To see the codes and breakdown of fees and negotiated fees and patient responsibility
My experience (at multiple dental / ortho offices) has been that the dentist has me sign an estimate, acknowledging what the insurance will likely pay, that its only an estimate, and that Ill pay the difference did sign anything along those lines?
Only pay the EOB. Even if you had xrays done, or had partial left over, if the EOB says you owe nothing, you owe nothing. I’d refuse to pay it, fight anything they try to send to collections using the EOB, and if they pursue it, report them to the state. I would also cut contact with them, and go find a new dentist, and wait to see if they press it. Chances are they know they won’t get anything, and are hoping you will just pay it, or hoping to sell it to collections and make a few bucks off something they realized they messed up. Them not contacting you back is a good indicator that you probably aren’t a patient of theirs anymore from their side anyway.
Dental insurance is not like medical insurance. With dental insurance whatever is not paid by the insurance company is paid by the patient. In a way dental insurance isn’t really insurance.
https://www.vox.com/23901293/dentist-delta-dental-insurance-cigna-aspen-metlife-aetna
Dental insurance is trash: you are responsible for difference.
If you are in the US, this is balance billing and it is illegal. This recently happened to me. I called insurance and they told me to call the provider and to call the insurance back if the provider gave issue with giving me a refund. Provider said theyÔÇÖd redo the bill and IÔÇÖd have to wait 7-10 business days to request a refund, so I called my credit card company to dispute the balance billing amount to get my credit back. I also reported my provider to cms.gov. I donÔÇÖt play around when businesses take advantage of people and do illegal things.
Just call the office and talk to them. It was probably a mistake. Depending on how or who posted the payment, it could be a system or human error.
It could be a shady office trying to get over on you but sometimes things happen and itÔÇÖs easily corrected.
If they fail to fix it, you can take it to the next level, but your first step should be to talk to the billing office.
I am sort of in the same boat. My wife goes to our same mutual dentist and she informs me that the billing person informed her that the dentist will no longer accept our plan. I had my own appt shortly after, so I of course ask about it when I am there. I mean, the plan is a dental ppo, not a limited hmo. Well, I was told our plan was too complicated and took forever to reimburse them so after the calendar year no more. I hate to change dentists, but fine, I ain’t paying more than I need to. My teeth are fine, a new dentist would be fine with me.
I would suggest that you call back your insurance again and ask them for advice. If contractually, your dentist is in the plan as in network and say through the rest of the year, I would suspect that you shouldn’t have to pay the excess. I doubt they will take you to court for it, but it will mean of course you need to find a new dentist.
Don’t overthink/overstress it. Call your insurance and explain the situation to them (feel free to use the term “balance billing” as it’s what’s happening here). Then ask them to handle it. I’ve been in several similar situations with different offices and insurance providers and every time that’s how I resolved it. Sometimes they handle it on their own, sometimes they make a 3-way call.
I would find out if balance billing, no surprise act applies to dentistry as well. I would be surprised as they have carved out a pretty nice niche for themselves.
Send a letter to your state insurance commission and a copy (carbon copy clearly noted on the letter) to the insurance company AND the dentist. That usually gets their attention.
If youÔÇÖre in the states, contact your attorney general. If IÔÇÖm not mistaken, what they are doing is illegal. Report them, because someone else isnÔÇÖt going to be as savvy as you.
Find a new dentist.
Asks your insurance carrier to contact the provider. The provider has agreed to the payment scale and is required to follow that fee schedule. If the dentist still refuses to follow the contracted rates file a complaint with the insurance commissioner in your state. Then look for a new provider.
If you like the dentist, which after this you may not, you could just roll over your payment.
ItÔÇÖs absolutely illegal for them to do that to you, but IÔÇÖve been in a situation before where I was fond of my dentist. All that happened was that what I owed and paid was rolled over onto the next time I went. Had to go through some loops, but it did get resolved.
But to be fair, I had fillings done the next time which wasnÔÇÖt fully covered for me. I was paying some part out of pocket.