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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-9

u/Old_Draft_5288 Jun 08 '25

You are opting for a more expensive product (Invisalign) than traditional braces for aesthetic reasons

Your Dentist likely has a negotiated rate for some of the service they perform, but because you’re opting into Invisalign, you almost certainly owe more out-of-pocket

Your dentist is offset what they can, but if you don’t want to co-pay, you need to go with a much lower end product

2

u/ChickenGooooood Jun 08 '25

But they charged the full amount to the insurance ($6000 for the cost of my Invisalign)

6

u/Woodman629 Jun 08 '25

The above explanation is 100% wrong.

0

u/MikeUsesNotion Jun 08 '25

That's normal. The fee adjustment column is adjusting it to the contracted amount.

-9

u/Old_Draft_5288 Jun 08 '25

Put simply, you may need braces but you definitely don’t need Invisalign.

6

u/Woodman629 Jun 08 '25

100% wrong. D8090 is service code. It is what is payable regardless of the method of alignment. Brackets and Aligners bill with the same fee for Delta.

-4

u/imnotlibel Jun 08 '25

That’s not true at all. I worked for Delta for over a decade. Most Delta plans do not pay cosmetic fees, they pay for conventional. However, this person’s EOB should list an D8999 miscellaneous code indicating the fee difference is their responsibility. It sounds like the office didn’t disclose it was Invisalign or the insurance missed it.

5

u/Woodman629 Jun 08 '25

You are wrong. I do this every day. Method doesn't matter. Alignment is the issue. Clear aligners are not considered cosmetic.

1

u/Woodman629 Jun 08 '25

The patient can also argue that D8999 is improper coding.

1

u/Woodman629 Jun 08 '25

You are under the mistaken impression that clear aligners = cosmetic. That is absolutely wrong. Clear aligners are quickly becoming the method of choice. Elastics can now be used with many clear aligners allowing for a more precise bite. Aligners are also a method of choice because of general hygiene. Not having brackets leads to less post-ortho decay and enamel discoloration. Assuming clear aligners are used because of vanity is dangerous and incorrect. Working for an insurance company certainly doesn't lend to properly understanding treatment enhancements, methodology, or improvements in techniques. For insurance, it's another claim.

-1

u/imnotlibel Jun 08 '25

Not even wasting the time reading this, traditional bonding is conventional treatment. Amalgam fillings are conventional treatment. Alternate benefits exist for a reason homie.

6

u/Woodman629 Jun 08 '25

from the article: 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.

3

u/Woodman629 Jun 08 '25

BTW --- orthodontics is the movement of teeth to correct misalignment, mal-occlusion, and other bite irregularities. The METHOD of movement is discretionary.

2

u/Woodman629 Jun 08 '25

Because you are 100% wrong. Good luck.

1

u/Woodman629 Jun 12 '25

from the OP in DM: Delta representative just read straight from her handbook to me that billing for Invisalign and metal braces are no different as of March [this year].

0

u/Woodman629 Jun 08 '25

Good catch on the D8999... that is the issue that could raise to the level of fraud.

0

u/imnotlibel Jun 08 '25

Nahhhh my internet insurance friend. I left corporate insurance to be a coordinator at the office level. Our contracts specifically state patients’s are responsible for the cosmetic difference. You clearly never worked for any of the Delta Dental plans association. Chapter 9 of their guidelines (national delta dental policies, not specific to the state) clearly indicate d8999 is a miscellaneous code BY REPORT. A report is a narrative…. A narrative indicating it’s Invisalign is deniable not disallowed even for participating providers. It’s the same shit for Veneers vs crowns… I’m telling you Invisalign is not a conventional treatment.

3

u/Woodman629 Jun 08 '25

https://www.dentalmanagers.com/blog/orthodontic-aligner-insurance-changes/

Orthodontic cases using traditional brackets and wires are coded the same as cases using clear aligners. Charges for clear aligners are currently being submitted to insurance using the appropriate orthodontic procedure code (D8010-D8090), followed by D8999 the Unspecified Orthodontic Procedure, by report with an additional “optional service” fee.

1

u/Woodman629 Jun 08 '25

It is well documented that lab fees for in-network providers will be disallowed regardless of the service (D2740, D2962, D8090 etc).

3

u/Woodman629 Jun 08 '25

more from the article --- It is recommended to contact a benefits representative at the PPO company before performing any optional services. PPO contracts control the fee and should be asked how to report and charge (with the patient’s written consent) the extra fee for this optional service. Most insurance payers have historically allowed the provider to balance-bill the patient for the “upgraded” treatment. This extra fee has been charged to cover the lab fee for the aligners, which can be very expensive, $1500-$2000 per case.

** Note -- This is no longer allowed under Delta.

3

u/Woodman629 Jun 08 '25

Does Delta Dental charge for Clear aligners?

  • As of 2022, Delta Dental of California is changing the game. Their website states: 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.

2

u/Woodman629 Jun 08 '25

It is not a cosmetic difference. I've been in dental for 27 years. D8999 is not the proper coding unless there is not other code that can define... i.e. something architectural or complications that arose during treatment.

Clear aligners are 100% conventional treatment. LMAO.

1

u/Woodman629 Jun 08 '25

You are clearly misunderstanding the term "conventional braces" not conventional treatment.

2

u/Woodman629 Jun 08 '25

from the article: 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.