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/Working_Coat5193]

Your dentist charges 6K for Invisalign. Your insurance paid $3,800 You owe 2k approx.

What’s unclear here? Presumedly the office explained this to you and told you were responsible for non covered charges?

[u/jamjamchutney → u/Working_Coat5193]

That's absolutely not how that works. When the provider is in network, they've agreed to the allowed amount as part of their contract - that's the whole point of in network providers. Balance billing would be in violation of the contract.

[u/jbert99 → u/jamjamchutney]

Exactly. When the office signs their contract, they're agreeing to accept $3879 as their total amount from delta patients. Half comes from Delta and then half comes from the patient (at least in this case).

[u/Haunting-Estimate985 → u/jbert99]

Not when the eob says that they have a contracted amount and the person is responsible for the rest. That means that it is an allowed billed amount they have, and this charge went over it, and the patient can be balance billed.

[u/jamjamchutney → u/Haunting-Estimate985]

No, an in network provider cannot balance bill the patient. The in network provider already agreed to accept the allowed amount. The patient only pays the amount the EOB says the patient owes.

[u/Haunting-Estimate985 → u/jamjamchutney]

Correct. Which means they have an allowed amount, not a contracted rate, and the patient is able to be balance billed.

[u/jamjamchutney → u/Haunting-Estimate985]

The allowed amount is the negotiated rate that the provider has agreed to accept. That is the contracted rate, i.e. the amount that's in the contract that the provider and the insurance company agreed to. Again, an in network provider cannot balance bill. The patient pays the amount the EOB says the patient owes, and that's it.

[u/Woodman629 → u/Haunting-Estimate985]

Not how that works at all. Allowed amount = contracted rate

[u/Woodman629 → u/Haunting-Estimate985]

You have no idea what you are talking about. You are 100% wrong.