r/HealthInsurance • u/ChickenGooooood • Jun 07 '25

Dental/Vision Is this insurance fraud?

I got Invisalign. My dentist submitted the claim to insurance for $6000. The insurance negotiated the price to $3800. The dentist still wants me to pay $6000 with my insurance covering $2000. The statement from my insurance says I only owe $2000 but the dentist wants $4000 from me.

UPDATE: I just called Delta dental. They confirmed my dentist is an in-network provider. The office billed 6k and the contracted rate for Invisalign is $3879, of which I am responsible for half. I already made a 1.5k down payment prior to starting treatment. The office is trying to bill me $3500 instead of $1939. This is considered balance billing and is a violation of the contract my dentist has with delta dental. I can open a grievance with them if they do not comply.

Question.. if I signed an agreement prior to receiving a letter from my insurance, am I required to pay?

I don’t want to make things super awkward considering I just started my treatment. I’m going to send the following email (so I have documentation). I’m welcome to suggestions to make this less awkward.

Good morning,

I hope you’re doing well. I’m writing to clarify a billing issue I noticed regarding my Invisalign treatment which I attempted to clarify with you at my first appointment. I contacted Delta Dental for further clarification and they confirmed that the contracted rate for Invisalign with in-network providers is $3,879. Delta will cover 50% of that amount, and my responsibility as the patient is $1,938.

Delta also confirmed that Dr. G is an in-network provider. As such, billing me beyond the contracted rate would be considered balance billing and would not align with Delta Dental’s in-network billing guidelines.

I truly appreciate the care I’ve been receiving from your office and want to make sure we’re all on the same page. I’m bringing this to your attention in the spirit of transparency and to ensure that everything is handled in accordance with the insurance agreement.

After double checking my file, could you please confirm the balance I owe considering I already made a downpayment of $1500.

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31

u/Woodman629 Jun 07 '25

Are you sure $3800 wasn't what was allowed? Allowed and billable are diffferent things for OON and IN.

There really isn't enough information here to answer your question. Is the dentist in or out of network?

$3800 would actually be incredibly low for ortho in most parts of the country.

13

u/ChickenGooooood Jun 07 '25

Thanks for your response. Sorry forgot to mention the dentist is in network. Here’s the letter from my insurance.

45

u/Woodman629 Jun 07 '25

Yep, you only owe $1,939.50. Full stop. It's not insurance fraud because they are trying to collect more the allowable. It's just dirty. Or more likely, a non-seasoned employee who doesn't know what they are doing.

67

u/AlternativeZone5089 Jun 08 '25

It is a violation of the insurance contract, and OP should not pay it and should file a grievance with insurance company.

11

u/ThellraAK Jun 08 '25

Are in network dentists actually a thing in some places still?

2

u/eapocalypse Jun 09 '25

All over but from my research most dentists are starting to drop insurance networks, and sounds like delta ,which OP has is one of the first they are dropping.

10

u/Haunting-Estimate985 Jun 08 '25

It literally says straight out that patient responsibility is 1,939.50. That’s what he owes them. The insurance is telling him that.

1

u/Ok-Seaworthiness-542 Jun 09 '25

But that is the patient’s share of the allowable amount, not the difference in the $6000 billed amount

3

u/Haunting-Estimate985 Jun 09 '25

Correct, which is why I recommended that they take the eob to the dentist, and say they are only paying this, as that’s what insurance says they owe. If they give a hassle, you call the insurance and the insurance will call the drs office and figure it out . If the Dr won’t give it back; a lot of times the insurance will pull the money from the Dr and repay the patient.

1

u/Wihomebrewer Jun 14 '25

The provider can’t charge past the allowable amount period. It’s double dipping when they already signed an agreement with delta that this is the price for that op code

23

u/Jcarlough Jun 08 '25

Well, it may not be allowed if the provider is contracted with the OP’s insurer - AND if the service received is a covered service.

Balance Billing as an in-network provider is contractually a big no-no (usually).

15

u/Woodman629 Jun 08 '25

That's what I said. She owes $1,939.50. The provider can not balance bill. It is not insurance fraud though.

3

u/ChickenGooooood Jun 08 '25

It’s illegal though, right?

19

u/AlternativeZone5089 Jun 08 '25

"Illegal" and a contractual violation are not the same thing. This is a contractual violation and it is not legitimate. OP is a third party to this contract and should appeal to insurance company to enforce it via a grievance unless a simple call to the billing office pointing out that they are charging more than the EOB allows fails to clear it up.

9

u/Woodman629 Jun 08 '25

It's contractual. By billing you more than $1.939.50 they are not in compliance with the contract they've signed with Delta.

3

u/ChickenGooooood Jun 08 '25

Right. That’s what I concluded.

2

u/Ok-Seaworthiness-542 Jun 09 '25

Last time I checked Delta was pretty serious about it as well. That benefit of only paying the discounted/negotiated rates is a selling point for them.

1

u/ChickenGooooood Jun 08 '25

So what can I do about it?

11

u/Woodman629 Jun 08 '25

Call the office. But as another poster stated this is not an explanation of benefits. This is a pre-pricing estimate. Have you started treatment?

If the office isn't responsive, contact Delta and ask them to do a 3way call with the office. Delta will explain it to them with you on the line.

5

u/ChickenGooooood Jun 08 '25

I already asked the office. I brought the letter to the first appointment (I did start treatment). She told me to ignore the letter and just pay what I’m billed. I mean, it’s not her responsibility to explain it to me, but that was a horrible response imo

9

u/Woodman629 Jun 08 '25

Unless the Delta you are under has a special carve-out for clear aligners, which is exceedingly unlikely, the office is not correct.

To be 100% sure, I would contact your Delta Dental plan and confirm that the fee they allowed for D8090 is for full treatment regardless of the method. Explain that you are doing clear aligners and be sure that the plan you have doesn't specifically allow for an additional fee. Again, that would be exceedingly rare.

3

u/Woodman629 Jun 08 '25

You are getting a lot of abd advise in this thread.

Charges for clear aligners (e.g. Invisalign®, SureSmile®) should be submitted using the appropriate orthodontic procedure code (D8010-D8090). The benefit is based on the approved fee for conventional orthodontics. Any additional fee for the nontraditional method is not billable to the patient.

1

u/Ok-Seaworthiness-542 Jun 09 '25

You really need to talk to Delta.

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2

u/Few_Captain8835 Jun 08 '25

If they're in network, then a likely pay off the contract is that they have to accept the contracted rate as payment in full. So there is a distinct possibility that they are violating their contract worth insurance by trying to balance bill you. I would contact your insurance.

1

u/Selah437 Jun 08 '25

Some states have laws against balance billing, but not all. I live in Missouri and have dealt with this. My insurance company contacted the provider and let them know it was illegal in Missouri, and they adjusted my ER physician bill. This was in 2018, so not sure if things may have changed since then.

5

u/anonymowses Jun 08 '25

Medical and dental have separate rules.

1

u/Ok-Seaworthiness-542 Jun 09 '25

It is a violation of the providers contract so whatever it is labeled (fraud, illegal, etc.) it is not allowed.

-8

u/Old_Draft_5288 Jun 08 '25

Not exactly the poster is opting into a known more expensive treatment, which is purely for aesthetic reasons.

3

u/Woodman629 Jun 08 '25

Not true. With Delta, the Invisalign fee and traditional ortho fee are the same. Yes, the lab fee is higher with Invisalign. That's a choice the provider makes.

D8090 is a service fee "Comprehensive Orthodontic Treatment" -- how you get there is a provider option. The fee doesn't change.

0

u/Complex-Royal9210 Jun 08 '25

Not for dental typically.

-4

u/Working_Coat5193 Jun 08 '25

Dental insurance expects dentists to bill over what they pay. This isn’t health insurance. OP owes 1900+.

9

u/Woodman629 Jun 08 '25

100% wrong for in-network providers. The contractual obligation is the same. A dental office can not bill the patient above the allowable fee.

1

u/CoomassieBlue Jun 08 '25

Sometimes it really is the latter.

I had a handful of fillings that my dentist identified last July and when I got home and compared the quote to my insurance plan coverage, it was all fucked up. Didn’t have time to get them done anyway so re-engaged at an appt this Feb.

Front desk was putting together a new quote and I mentioned the last one seeming off. They opened it, basically said “wtf”, and commented that the person who generated the first quote no longer works for them.

1

u/FlourideDonut Jun 09 '25

There’s nothing dirty here. OP used approximations ($3800, $2000) when the bill clearly states the allowed amount is $3879 (I.e. not $3800) and $1939.50 (co-pay is $50%). This all looks kosher.

1

u/Woodman629 Jun 09 '25

The office is trying to collect an additional $2k.... (above the $3879)

1

u/Woodman629 Jun 07 '25

You must be in middle-America. That is a pretty low fee. In WA, our allowed with Delta significantly higher. Like 33% higher.

1

u/ChickenGooooood Jun 08 '25

Could it be bc we have a good plan and they were able to negotiate the cost? I honestly don’t know how this works.

7

u/Woodman629 Jun 08 '25

No. The fee is pre-determined with Delta and is an in-network, contractual fee.

The office has access to the fee schedule they have agreed to.

Somebody is asleep at the switch.

A phone call to the office should clear it up.

1

u/Long-Raccoon2131 Jun 11 '25

What is your ortho lifetime maximum on the policy? That's whst matters. Most if you're lucky is 1500. While your EOB shows 50% you are responsible for if your lifetime max is 1500 then the Doctor can legally bill you any excess not covered by the plan. Let's say I bill 6000 but the plan negotiated it to 3879 and they paid me 50% which 1939.50. If your lifetime max is 2 grand I can bill any amount past 2 grand because now insurance is not covering it. This is where people confuse dental with health. Health you reach the max to get 100% coverage with dental you reach the yearly or lifetime max that's it game over the excess is billed as the dentist wants to.

1

u/ChickenGooooood Jun 11 '25

Interesting. I have a max of $2000. I called delta and they said the dentist shouldn’t be billing me more than the $1938.

1

u/ChickenGooooood Jun 11 '25

Isn’t the negotiated price ($3800) the new price though, not $6000?

1

u/sloppypocket Jun 12 '25

Invisalign is considered an upgraded/cosmetic option for orthodontic treatment. D8090 is the code for basic orthodontic treatment which would just be metal braces. Typically there’s going to be an additional up-charge for clear aligners…. Did you ask them what their office fee is for Invisalign? Because most likely it is an additional fee on top of that $3879 which insurance likely would not pay towards. On the treatment plan that the office provided there’s probably a D8999 code showing the upgraded procedure amount. $6k seems pretty typical for Invisalign IMO

1

u/ChickenGooooood Jun 12 '25

I called Delta. As of March Invisalign is covered by my dental insurance. They said I shouldn’t be charged beyond the contracted rate.

1

u/sloppypocket Jun 12 '25

Nice, that’s new! Maybe they were unaware of this as well. I’d get them on a 3 way call with an insurance rep so that they can clarify things on your behalf

1

u/DomesticPlantLover Jun 07 '25

That says per-treatmet estimate. It may not be the final statement. But it would appear that you are only liable for this amount listed as "Patient Payment. According to this estimate.

But, again the paper says "estimate." That's not the final billing. Perhaps the dentist has left the network.

2

u/ChickenGooooood Jun 08 '25

She billed the whole treatment ($6000) so wouldn’t I only owe what’s shown ($1939)?

1

u/DomesticPlantLover Jun 08 '25

You might. All I'm saying is what you posted is not an OEB, which would state what you owe/can be billed. This is it's an estimate. Estimates change.

1

u/Woodman629 Jun 08 '25

That is simply wording. Estimate is what Delta uses to provide pre-pricing information. This would not change based on code D8090.

0

u/DomesticPlantLover Jun 08 '25

My point. Things might have changed.