Insurance question--being charged when it says you won't be

[Rock'n Robin]

Last December my kids had their annual dental visit. All but $38 was covered for each child. I got billed soon after for that amount. Hmm, I thought, I thought that my statement said "your provider agrees to this amount". I didn't worry enough about it to go dig up the statement the insurance company sent, though.
Well lo and behold, I just got the statement from their June visit. All but $38 is covered for each child (except for an $8.20 copay for DD#1, who had a cavity). And it DOES say "your provider agrees to this amount".
Now if they bill me again, does this mean they are lying to the insurance provider? This is a dentist office I have gone to since 1968 (although then it was the current dentist's father) and a very small practice, their statements are still handwritten. It will only take a little bit of a nudge to get me to switch, since this guy has very little bedside manner. I haven't been to him myself for 4 years, although I make the kids go twice a year. But they are very good about scheduling after school or on vacation days, since I'm a teacher and don't like taking sick days because "we don't see appointments after 2PM" like some dentists. I just don't want to cough up this cash if the insurance provider thinks I don't have to.
Robin M.

 

[BedKnobbery2]

It depends on your policy, so you probably will have to look it up, but generally speaking, yes--if the provider agrees to accept the fees set by the insurer, they cannot charge you above and beyond that amount.

 

[ahutton]

Generally you can't be billed for the difference if the statement reflects the provider accepts this amount. What I would do is send a copy of the Explanation of Benefits from the carrier to the office with his statement, maybe include a cover note asking why they are billing you based on the statement note?

 

[jennyanydots]

actually, I disagree. the statement "your provider agrees to this amoun" is boilerplate, and does nto reflect the contract you have with your provider or the arrangements he may have made with the isnurance company.

if your dental plan is an HMO or PPO and he's a provider for that plan, his contract with the isnurer probably provides that he can't bill you an amount in excess of the payment provided by the plan. if it's more along the lines of traditional insurance, he can bill you anything he wants.

I can't tell what type of plan you have or what arrangement this provider has with your insurer, so I can't tell you whetehr he's allowed to bill you.

but what I can tell you -- my ex husband's dental plan is a PPO, but some services are not covered by the plan. the provider will accept the plan's payment for a covered service, then charge whatever he wants for services not covered by the plan. when I had my wisdom tooth extracted, the dentist charged a "consultation fee" which "coincidentally" was exactly the difference between what the PPO provided and what he charged people with no insurance for the same procedure.

 

[tiggersmom2]

Originally posted by jennyanydots
actually, I disagree. the statement "your provider agrees to this amoun" is boilerplate, and does nto reflect the contract you have with your provider or the arrangements he may have made with the isnurance company.

if your dental plan is an HMO or PPO and he's a provider for that plan, his contract with the isnurer probably provides that he can't bill you an amount in excess of the payment provided by the plan. if it's more along the lines of traditional insurance, he can bill you anything he wants.

I can't tell what type of plan you have or what arrangement this provider has with your insurer, so I can't tell you whetehr he's allowed to bill you.

but what I can tell you -- my ex husband's dental plan is a PPO, but some services are not covered by the plan. the provider will accept the plan's payment for a covered service, then charge whatever he wants for services not covered by the plan. when I had my wisdom tooth extracted, the dentist charged a "consultation fee" which "coincidentally" was exactly the difference between what the PPO provided and what he charged people with no insurance for the same procedure.

This is right. I work in a Dental office and handled the insurance before becoming a Dental Hygienist. If your plan is a PPO and your dentist is on your PPO list (as a PPO provider) then he cannot charge you for covered procedures. BUT if he is not a participating dentist you must pay whatever your insurance does not pay.

 

[Rock'n Robin]

I did get through to the customer service of the insurance provider--the exact notes are A--the provider has agreed to the allowable amount for this service and B--this amount represents your provider discount.
The customer service rep said the dentist is under contract to "dentemax" and cannot bill me for the charges above what insurance covers.
Of course the dentist's office is closed until Monday at 8AM (they close Friday afternoons in summer--I told you it's a small office, with one receptionist, one hygenist and one dentist). I did leave a voice mail that I would like to discuss the billing from last December and why I had to pay over the amount insurance covered.
I am guessing that since they are under contract to the insurance co. they are a provider--they always file the paperwork, etc.--if they aren't a provider, they have never mentioned it to me! I just want to make sure they aren't committing insurance fraud--and I want a refund of that money I sent for the December checkup!
Robin M.

 

[LindaG4458]

I have had medical offices try to pull this on me. I reminded them that they were required to accept the insurance amount as payment in full. If they argued that "that wasn't their policy" I told them that the insurance company would be very interested to hear that. Then I filed a complaint with the insurance company and changed providers.

I hate it when they try underhanded stuff. If they are not gong to accept the assignment then they should drop out of the program.

 

[jennyanydots]

now you've got your answer form the insurer -- he's under contract. so now you have ammunition in the billing discussion.