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/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).

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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.

2

u/ChickenGooooood Jun 08 '25

It’s illegal though, right?

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.

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u/anonymowses Jun 08 '25

Medical and dental have separate rules.