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they're cheating me on insurance claims

rh71

rh71

No Lifer
Basically the receptionist at my dentist put in an extra code for work that I did not have done that day.

I contacted my insurance company and they were on my side saying the extra code does not coincide with having a regular cleaning done... the extra code should not be there... but they stopped caring at that point.

The receptionist refuses to budge, talked to her via phone and in person. She insists I pay for 35% of the extra code's charge (65% covered by insurance) which comes out to $75 out of my pocket. What's more is that she keeps changing her story as to why it should be there so I'm pissed.

What's the best way to contest this ?
- Contest via insurance company
- Write a letter to the dentist outlining all the lies


Anyone else deal with shady practices by their medical or dental providers ? My wife says I should watch out for them so she has had experiences too... but she was able to talk to the billing person at the office.
 
What is the extra code for? What service was not rendered that they charged you for.

Simply state that you aree not paying for services not rendered.

You could also call for the ATOT effect later on if your cause is just. Pull an ATOT effect thread asking for a lawyer that is willing to write a letter on your behalf. No sense paying a lawyer, but if you can get someone here to give you a hand 😉

Lucky me. I have a lawyer i nthe family so things liek this arn't much of an issue.
 
just say..... i'm not paying it and i want to talk to my doctor......if he is an ass then i would say again....
i'm not paying and if u want to persue this i will take u to the BBB report u for fraud and write a letter to the dental association
 
Don't talk with her anymore
Put your concerns in writing and send them certified to the doctor himself.
 
Ok, here's what I got... what do you think .. too wordy ?
On 12/21/2004, I received a letter from your office indicating I have an outstanding balance of $75.15. Confused as to why there was a balance left over after I had verified a $0 balance following my 10/26/04 visit, I called your office and spoke with Madeline. She indicated to me it was for the 10/26/04 procedures, and that my insurance only covered 65% of the ?Periodontal Maintenance? (code 04910). I did not have such a procedure performed then ? only a regular cleaning (code 01110), which is 100% covered by my insurance and appears in the claim as well. As a matter of fact, I clarified with Madeline and Iris (your hygienist) that all I was having done that day was a regular cleaning since I did not want any procedure not fully covered under my insurance done ? I had just gotten married and I was watching my expenses.

My account was adjusted to reflect a balance of approximately $29 after this call. There was no specific reason given for this credit to my account ? just that my records showed something was charged incorrectly in the past. Still concerned about an existing balance, I reached MetLife, my dental insurance company, and they indicated for the 10/26/04 visit, both a cleaning and a periodontal maintenance should not be claimed, especially for the same visit.

A few days later, I reached Madeline via phone again with this information and she indicated both claim codes (cleaning and periodontal maintenance) were submitted because in this way, I would be better off since I?d be covered for at least some amount since I had more than 2 cleanings performed for the year. First, I fail to see how submitting an extra code (one that I did not have performed and is NOT covered 100% by my insurance) would benefit me. It wouldn?t even work out in my favor if the cleaning was added for my benefit either ? since I would still owe the same amount for the periodontal maintenance. Second, I did NOT have more than 2 regular cleanings for 2004 ? MetLife has sent me all records of visits and procedures done.

On 1/4/05, I went into your office to question this further and was told yet another story ? that my insurance only covers 1 cleaning every 6 months. I called MetLife again the next day and they said this was false ? my policy covers 2 cleanings per year no matter how far apart. I confronted Madeline with this fact and she would not accept this, even after I asked to conference her in with a MetLife representative ? she would not hear of it. Yet another explanation was presented when she now says that it is mandatory procedure for ?periodontal maintenance? to be claimed after my previous work (scaling/root planning on 5/18/04 and 5/25/04) was done. Again, MetLife denied this was proper procedure for claims. On 1/6/05, I called your office and tried to clear this up again, but was told I would receive a call back instead. It has been more than a week without hearing back from your office.

I have respect for the staff at your office and mistakes happen, but you can understand my concern and growing distrust, especially after multiple explanations were disproved each time. I will accept no more. I am requesting this claim code 04910 (Periodontal Maintenance) for 10/26/04 be removed from my records and that my account balance be credited to $0, before any further parties are involved. Please verify that this will be done as soon as possible.

Thank you for your time and attention to this matter.
Click to expand...
 
Delete the part about getting married and watching your money, it's not relevant. Second, delete the last paragraph (and the sign off) and replace it with the second to last sentence of that paragraph.

Third, call Met and ask to speak to Met's fraud division and tell them what the dentist has been telling you.
 
thx... I've adjusted the last paragraph. I won't contact MetLife's fraud division just yet though - i still have intentions of doing regular cleanings there... everyone there is ok except the receptionist... I will just watch the claims like a hawk.
 
Very tactful and to-the-point letter, and good job watching crap you shouldn't have to watch. 🙂
However, be aware that...
Originally posted by: rh71
I contacted my insurance company and they were on my side saying the extra code does not coincide with having a regular cleaning done... the extra code should not be there... but they stopped caring at that point.
Click to expand...
...in this type of case, your insurance company will almost always be on your side - the more service they can deny, the more money they make. 🙂
 
well this one is easy. Just tell her that you are going to contact the BBB and whatever company that deals with insurance fraud. Be prepared to look for another dentist.
 
UPDATE: I just got a call from the dentist's office... she called and said my balance is now $0.

:thumbsup:
 
I guess your problem is fixed, but I can tell you that you had no chance with the insurance company on this.

You have to take it up with the dentist, or better yet your benefits administrator should be doing that. The insurance company provided them with the outline of what benefits(%s, dollar fees, etc.) you receive. Past that, it is not on the insurance company.

Unless the insurance company misread the claim the dentist submitted, it is not their problem.

Edit: After reading your letter, I have to ask: What city/area was this in?
 
Originally posted by: Wooglin
I guess your problem is fixed, but I can tell you that you had no chance with the insurance company on this.

You have to take it up with the dentist, or better yet your benefits administrator should be doing that. The insurance company provided them with the outline of what benefits(%s, dollar fees, etc.) you receive. Past that, it is not on the insurance company.

Unless the insurance company misread the claim the dentist submitted, it is not their problem.

Edit: After reading your letter, I have to ask: What city/area was this in?
Click to expand...
long island
 
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