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/Woodman629]

Are you sure $3800 wasn't what was allowed? Allowed and billable are diffferent things for OON and IN.

There really isn't enough information here to answer your question. Is the dentist in or out of network?

$3800 would actually be incredibly low for ortho in most parts of the country.

[u/ChickenGooooood → u/Woodman629]

Thanks for your response. Sorry forgot to mention the dentist is in network. Here’s the letter from my insurance.

[u/Long-Raccoon2131 → u/ChickenGooooood]

What is your ortho lifetime maximum on the policy? That's whst matters. Most if you're lucky is 1500. While your EOB shows 50% you are responsible for if your lifetime max is 1500 then the Doctor can legally bill you any excess not covered by the plan. Let's say I bill 6000 but the plan negotiated it to 3879 and they paid me 50% which 1939.50. If your lifetime max is 2 grand I can bill any amount past 2 grand because now insurance is not covering it. This is where people confuse dental with health. Health you reach the max to get 100% coverage with dental you reach the yearly or lifetime max that's it game over the excess is billed as the dentist wants to.

[u/ChickenGooooood → u/Long-Raccoon2131]

Interesting. I have a max of $2000. I called delta and they said the dentist shouldn’t be billing me more than the $1938.

[u/ChickenGooooood → u/Long-Raccoon2131]

Isn’t the negotiated price ($3800) the new price though, not $6000?