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/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.

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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.

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u/Woodman629 Jun 08 '25

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

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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.

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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.

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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).

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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.

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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.

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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.

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u/Woodman629 Jun 08 '25

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

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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.