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  • $2500 bill for unauthorized dental work for child - please help!

    I was billed for unauthorized dental work. I have Delta Dental insurance and brought my daughter only for cleaning that should be covered 100% as a preventive care. Then she started to complain about one of her teeth. I said that I agree to authorize ONLY the work that is covered by insurance and was assured that everything will be covered. Later I received a bill for $2,500 and learned that they lied and actually do not even participate in my Delta Dental network. They replaced all fillings my daughter has ever had without any reason! What are my rights to deny this bill?

  • Betty3
    replied
    Originally posted by Morgana View Post
    It is the responsibility of the insured to make sure that they Dr is in their network and if not, ask for a different referral.

    Even if the Dr's office says something is covered, I always check. Its safer in the long run. You have to be proactive.
    Definitely agree.

    Leave a comment:


  • Alice Dodd
    replied
    From the original post, it sounds like the dentist might have been scamming her by 'replacing all of the fillings' that the child had. First I would discuss it with the dentist and ask him to show the x-rays that show all fillings needed to be replaced (not likely in a child). Also do what others have suggested, call everyone you can think of to report it, especially the dental board.

    You need to write a letter disputing the bill and the necessity of the work, and also re-state that you ONLY authorized work that was covered by insurance, thereby putting the onus on HIM to verify that it was covered.

    However, it looks to me that he overstepped his authorization by doing unnecessary work, which is a battery and a scam.

    Many lawyers give a 30 minute free consultation, call your local bar association for a referral.

    Leave a comment:


  • TSCompliance
    replied
    Your sources are probably for employers and employees/consumers, so that does make sense. But all my sources are from the healthcare compliance industry, where our theme is that we have to think of everything, because you can't rely on the patient/consumer to do it effectively.

    Yes, my own health plan and the info from my HR dept tell me that it's my responsibility to make sure I'm covered for a service before I get it. And if it got as far as going to collections or to court, that would probably hold up.

    But healthcare providers are also beholden to CMS rules, which govern all Medicare & Medcaid services. If we provide a service to a Medicare or Medicaid recipient without first checking eligibility, we cannot turn around and bill the patient if it was our error and the patient was not covered. Whether a large portion or a small portion of a provider's patient population is on Medicare/Medicaid, we have to ensure that our organizations treat all patients equally (totally different from an employer setting) and that we don't "discriminate" against a person because of type of coverage. If we are doing something with Medicare or Medicaid patients that is "better" or "wrose" than with other patients, we can put our own eligibility as Medicare/Medicaid providers at risk.

    So did this dental office break a law? No. Did they adhere to a best-practice that would ensure that they are paid in a compliant manner? No. But if they have a big caseload of publically funded patients, they will be thinking in CMS terms, and they will likely just drop the charge and write it off because they were not doing their due diligence with eligibility verification.
    Last edited by TSCompliance; 01-03-2011, 10:26 AM.

    Leave a comment:


  • Morgana
    replied
    To piggyback off of TSCompliance, many people think that when a physician makes a referral to Dr X or writes a prescription for drug Y or requests certain test that the dr is aware of whether that physician is in your network or whether that drug is in your formulary or if your insurance covers that test.
    Thats not the case. It is the responsibility of the insured to make sure that they Dr is in their network and if not, ask for a different referral. If the drug isnt in your formular, you either pay for it or ask the dr for a substitution or have the Dr get a waiver.

    Even if the Dr's office says something is covered, I always check. Its safer in the long run. You have to be proactive.

    Leave a comment:


  • Betty3
    replied
    I just read too many posts, I guess, on various forums & it's in one of my own books that it is always the insured's ultimate responsibility to be sure that the work/procedure
    is covered by their ins. (not dentists or doctors) Some dentists/doctors have sued for payment & won. It is a courtesy, is my understanding, for the office staff to verify coverage.
    It might sometimes be found by certain judges if it goes to court that the dentist/doctor
    is at fault or shares some responsibility but it doesn't seem to be the norm.

    As cbg said, it isn't the dentist's fault either if the insured asked the wrong question. My dentist never verifies my eligibility before performing work. I do that.

    I'm sure some dentists end up writing it off and maybe send it to a collection agcy. but all do not.

    Leave a comment:


  • TSCompliance
    replied
    Speaking from the healthcare provider point of view, providers need to check eligibility before providing services (with emergencies being the exception). While in most cases I advocate for people being informed consumers, and if they snooze, they lose, in this case the provider does have a responsibility.

    We all get lots of patients/clients coming to us who have no clear understanding of their coverage, and how to find in-network providers. Even if a client says she knows she is covered by a plan in which we participate, we always run the info before the appointment. Most healthcare providers I've dealt with myself do something similar. Before the first appointment happens, I have to give insurance info and they check my eligibility. If they find I'm not eligible to have reimbursed services with the provider, they notify me, and I can cancel the appt. Even when I go to my dentist twice a year and gyn once a year, they re-run my insurance info through their system to verify my eligibility.

    So it might not be the dentist's "fault" but the dentist surely needs to have competent office staff who check patient eligibility before the service takes place. If they did not verify eligbility, then it's their fault. They'll end up trying to collect from the patient, and when they don't get paid, they end up sending it to a collections company and writing it off.
    Last edited by TSCompliance; 01-03-2011, 08:26 AM.

    Leave a comment:


  • Betty3
    replied
    The OP can do as they wish. However, this might not be the insurance company's
    and/or the dentist's fault. Just saying ......

    The OP authorized what the ins. co. would only pay & might not have given the dentist the
    complete name of his network/plan. It would not be the dentist's fault as cbg noted. I agree.
    Also, why would the ins. co. pay for work they probably weren't called to verify if they
    would pay for & pay if OP not a member of their network? I'm not saying that is the case
    here but certainly seems like it could be.
    Last edited by Betty3; 12-31-2010, 09:04 AM. Reason: spelling

    Leave a comment:


  • drruthless
    replied
    Das ist in der Doktor!

    A few years back we had a similar situation to what you're describing taking place here in town.
    Several dental clinics owned by the same Doctors were found to be defrauding customers by doing unauthorized work and submitting bills to the state for procedures that was never done or unnecessary.
    We, having not been there in the room with you, can only speculate as to what did or did not take place.
    The bottom line is, you have been given a bill for $2500 dollars for work you may or may not have authorized that must be dealt with.
    I would urge you follow up using any or all of the resources that I’ve suggested.
    I'd start with a local TV station.
    This may be the beginning of a long up hill battle
    Good luck

    .._________________________
    ~ Free advice is like a public defender,
    …you get what you pay for. ~ drr

    Leave a comment:


  • Betty3
    replied
    Agree with cbg. A lot of times it's not the ins. company's or dentist's fault. Therefore,
    it becomes the insured's responsibility for what the ins. co. doesn't pay.

    They can try to see if they can get some of the cost reduced (they can ask).

    Leave a comment:


  • cbg
    replied
    Approximately 95% of all dentists participate in Delta Dental, the last I heard. However, they may not all participate in all possible networks. For example, if there's a Premier network and a Premier Plus network and a Standard network, a dentist might participate in the Standard and the Premier, but not the Premier Plus. When this happens it can get confusing; the patient says, "I have Delta Dental - do you take that?" and the dentist truthfully says Yes. What the patient should have said was, "I have Delta Dental Premier Plus - do you take that?" but s/he didn't. (I am speaking generically - I am not speaking of this particular poster.) It would be nice of the dentist to say, "Well, I participate on the Standard and the Premier networks, but not the Premier Plus" but nothing requires that he do so, and that is not the question the patient asked. He gave a truthful answer to the question that was asked; the fact that the patient asked the wrong question is not his fault. This happens FAR more often than you would believe; when I have employees ask me about the networks I counsel them on how to ask the right question, but not everyone asks me.

    So, quite frankly, I'm not convinced that the doctor lied; I think it's far more likely that the doctor answered the question asked of him but that it was not the right question.

    Leave a comment:


  • drruthless
    replied
    Betty,
    I think there is something we’re missing here.

    I received a bill for $2,500 and learned that they lied and actually do not even participate in my Delta Dental network
    Does this fact change anything ?

    Leave a comment:


  • Betty3
    replied
    I was first taking it that the dentist told you your ins. would cover all - they verified. Was it the dentist who said that or Delta Dental Ins. who said that to *you* when you called Delta Dental to verify coverage. It's not the doctor's responsibility to see that your ins. covers everything- you need to verify with the ins. co.

    Leave a comment:


  • TSCompliance
    replied
    To piggyback on what the Doktor wrote, also report this to the state board of licensing for dentists. And to alert other consumers, post it on sites like Yelp (free) and Angie's List (fee based).

    Leave a comment:


  • HRinMA
    replied
    How did you not notice work being done on multiple teeth? A filling replacement takes only 45 minutes so she must have been in the chair much longer.

    Speak with Delta to see if you can get reimbursement if you pay part of the bill. Also did you get billed for the cleaning if Delta was not accepted?

    Leave a comment:

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