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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u/ChickenGooooood Jun 08 '25

It’s illegal though, right?

10

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.

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u/ChickenGooooood Jun 08 '25

So what can I do about it?

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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.

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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

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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.

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u/ChickenGooooood Jun 08 '25

Great, thank you for your help!

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u/Woodman629 Jun 08 '25

Dental codes are reviewed yearly by a panel of experts. To date, the ADA has not adopted an ADA code that specifies the method of alignment. Comprehensive Ortho is billed as D8090.

There have been requests by offices and providers to create a different code for Comprehensive Ortho based on the modality (tradtional brackets, SureSmile (which is robotic enhanced), and aligners. Some have even advocated for a code the specifies if the braces are placed facially (on the front of of the teeth) or lingually (on the back of the teeth) but that hasn't been approved for coding purposes.

That is also why so many orthodontists are out of network now. The restrictions on fees are too costly for the office.

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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.

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u/Ok-Seaworthiness-542 Jun 09 '25

You really need to talk to Delta.