Is this insurance fraud?

[u/ChickenGooooood]

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.

[u/imnotlibel]

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.

[u/Woodman629 → u/imnotlibel]

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

[u/imnotlibel → u/Woodman629]

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.

[u/Woodman629 → u/imnotlibel]

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.