Seeking Advice: Issue with Dentist/Insurance

[Deleted]

Okay, I finally got around to registering on this board after migrating from MSN Money.

I have an issue with my dentist/insurance that I could use some other opinions.

Story: I've been going to my current dentist for about 3 years, and have never had any problems in the past. Each time a service is preformed I pay whatever isn't covered by insurance on the spot and dentist processes insurance portion. I've never gotten an invoice in the mail nor have any reason to believe there were any issues with my account.

Last week I received a letter in the mail from my dentist saying I'm over 90 days past due on prior charges and was also slapped with a finance charge. I was directed to pay within the next 10 days or otherwise face additional finance charges and have it taken to collections or whatever other escalation procedures.

A few days later I receive a call from someone at the dentist office who wants to discuss my account. She is very friendly and explains that the charges result from services not being paid by the insurer that they initially assumed would be, but given that I was a valued customer and never had any issues with me before, they'd be more than happy to wave the finance charges. She then asks if I'd like to make payment and clear the account so no further changes accumulate. I'm hesitant and say I'd look to look into the charges and check with my insurance company before making payment. She backs off a bit and says okay, but that my account will accrue further finance charges by the end of the week.

So I call my insurance company and find out the reason the services were not covered was because the claim was filed over 6 months after time of services rendered...i.e. no longer valid. The claim stemmed from a general cleaning and oral evaluation from late 2009...that should be 100% covered. Insurer has no record of claim prior to late December 2010. So I call back person at dentist, explain what I found out, and ask why claim wasn't filed in a timely fashion. She fidgets a bit, but then confidently explains that this was the second or third time they'd filed the claim and had finally received rejection of payment in Dec 2010. I ask if she can provide some sort of proof of this so I can go back to the insurer and have them reconsider the claim. She says that would be unlikely given that everything is submitted electronically...but that she'd look into it. (I'm already suspicious at this point.) I call back person at insurance company and explain situation (they are very understanding and helpful), and inform me that if the claim was previously submitted electronically, they would have an electronic tracking number, and assured me the dentist or TPA would have to keep records of this. If they were able to find this, the insurer would be more than happy to address the situation. This all happened late last week, and since then I've tried getting a hold of this billing lady in charge at the dentist...each time I've first gotten the receptionist, who puts me on hold to transfer and then informs me that this lady is in a meeting, on a call, etc....please provide a message and she's get back to you.

Long story short, it appears evident that my dentist forgot to file a claim from 2009 and now are putting me on the hook for it and are unwilling to take responsibility. It clearly states in my insurance info that claims must be submitted within 6 months of service, so nothing forcing insurance company to pay it at this point. There doesn't appear to be anything holding the dentist legally responsible for paying, as the billing lady reminded me that they submit claims as a courtesy to patients but patients are always ultimately responsible for whatever insurer doesn't cover.

So what do I do at this point? It's $160...not life changing...but this type of crap annoys the heck out of me. Do I just pay it, move on, find a new dentist and give them a bad review? Do I have any legal recourse worth pursuing at this point?

[shanendoah]

(Please note that I work for an insurance company, and up until 7 months ago, worked directly with the Appeals team. I know of what I speak.)
What you do is get an invoice from the dentist and file an appeal with your insurance company. This is a charge that should be covered 100% by the insurance. The insurance company then looks at the charge, does the research to make sure the dentist did, in fact, submit the claim late. Then they deny your appeal as "proivider responsibility". What this means is that the insurance company doesn't have to pay for it becuase it was submitted late, but also that you do not have to pay for it because the fault was that of the provider. The contract the provider has with the insurance company almost certainly prevents them from charging the patient when the fault is the provider's. If, on the off chance, their contract does not have this clause, when your insurance company denies your appeal, they will let you know that you need to pay it. However, there's also the chance that, given the circumstances, the insurance company will go ahead and pay, despite the claim being filed late, in order to avoid one of their members having to pay for a service that is supposed to be covered 100%.
And whether or not you find a new dentist depends on how much you like your actual dentist.

[Gardening Grandma]

shandendoah
I am cuting, pasting and saving your response. I've never had a problem with our dentist's billing, but this is great information! Thank you!
OP: I'd take shandendoah's advice about the billing problem, but I would not change dentists unless you were dissastified with his/her work. The problem is with the office person who messed up.

[whoisjohngalt]

Shanendoah,

I am saving your response as well, but was wondering - why is it up to ME to do all the leg work if the dentist clearly dropped the ball? And why SHOULD insurance company pay??

thanks
Lena

[Deleted]

shanedoah,

Thank you for you response. Unfortunately, it doesn't seem to be working out this way. Billing lady at dentist office is holding fast that claim was submitted prior to 6 month window. However, she can provide no proof...says their TPA doesn't keep records of such submissions beyond 4 months. Insurance company says unless proof can be provided that a claim submission was made within the 6 month window, they will not reconsider payment. Basically told me it's between me and my dentist office to sort it out.

Dentist office isn't willing to take any responsibility for this, or even willing to split the bill as a peace-offering...this is what I suggested after little progress. I finally pressed and asked how she could even be sure the claim was properly submitted if they have no records of it??? Well, she said all claims are submitted at the end of each day, simple as that.

Anyhow, this is pretty much the last straw with this place. My dentist left last fall, so I'm not really attached to any dentist there at this point. Additionally, after this whole fiasco, I checked them out on yelp.com....(this is a very useful tool for reviews of local businesses) and found that they've had some pretty nasty reviews the last couple of months.

My business is moving elsewhere at this point. And I've already wasted at least a half-day of my time and my company's time.

[whoami]

I had this problem with my dentist. I told them I wasnt paying it. They didnt file appropriately and then couldnt even tell me what the charges were for. I guess they decided to write off the $400 considering the amount of money they made off of us every year. This was 5 or 6 years ago. My dentist vanished about a year ago, stiffing some company she sold her accounts too by filing claims for accounts she had sold to them. The billing company then came after us. I provided all the paperwork proving the claims they were billing me for were paid to her and provided receipts for the copays we also paid to the dentist. I got a paid in full statement from them. I wonder how many other patients dont keep their records as well I do.
They are probably screwed. Nobody seems to be able to locate her at this point.

[whoisjohngalt]

Jim

If it were me, I would just tell them flat out - take me to court. Let the burden of proof be on them. If they do, and J or Swamp correct me if I am wrong, you probably won't even need a lawyer.

I can't stand being bullied around and don't handle it well

Good luck!!
Lena

[whoisjohngalt]

If you are worried about your credit score (I don't know if those type of bills have an effect on it), pay it and then take THEM to small claims court. Again, you won't even need a lawyer.

I just get really irritated when people screw up and don't take responsibility for it!

Lena

[zibazinski]

I'd do the same thing. Tell them to take you to court but since people are able to put things on your credit without it even being true, I think I'd sue them first. I'd tell them I was going to file suit against them for mishandling your claim and for threatening you with damage to your credit if you didn't pay for their mistake. They must be losing business due to their shoddy practices. I might also picket in front of their office as well as bad mouth them to anyone that will listen, but that's me. I got refunded a $500 deposit by threatening to picket in front of the place of business so I always like that one.

[Deleted]

Lena,

I completely agree with you. This kind of BS ticks me off to no end. If I bend over and pay it, they win, and go on hosing others patients just like me. If I don't pay it, they take me to collections, ruin my credit score, and I have to go through all the work to refute it, get my credit cleared, etc etc. It's $160. I just don't think it's worth the headache.

I think I'm going to stop by their office later this week, put in my 2 cents with this billing manager, pay the charges, cancel any future appointments, tell them that's not the way to treat your customers and let them know them I will tell everyone I know in the city what I think of them and their practices.

Maybe I should make a scene at the dentist office? I've never done anything like that before and always wondered what it would feel like.

[zibazinski]

It feels DAMN good and I'd do it BEFORE you went in to pay your bill. DEMAND your charts as well and don't let them BS you about a fee for doing it. Plus, I'd talk to the dentist.

[shanendoah]

jimmo: Call your insurance customer service. Do not go into an explanation of what happened, simply tell them that you want to file an appeal and to please direct you to the member appeals department. When you talk to an appeals representative (often an admin at the first stage), simply tell them that your provider is billing you for a service you believe is supposed to be 100% covered. DO NOT get into when the claim was filed, etc.
Then, let the insurance company and the dentists office argue over whether or not the claim was filed in a timely manner. This should NEVER be your responsibility. If your insurance company tries to give you lip over filing an appeal, contact your state's insurance commissioner/department of insurance. You ALWAYS have the right to appeal a decision by your insurance company, and the state regulators can help you.

Lena: In fact, it shouldn't be up to you to do the legwork. If the bill you get says "denied by insurance" and you believe it should be covered by insurance, then all you need to do is call the insurance company and start an appeal. If the bill doesn't have a note, you do need to call the office and make sure they billed the insurance company, but that is all the work you should ever have to do.
The insurance company should NOT have to pay. At my company, this appeal would be denied, but denied "Provider Responsibility" (as opposed to Patient Responsibility). That means that the fault was with the provider, and they are not allowed to bill us or our members for the service. That is built in to all of our contracts.
However, insurance companies will sometimes go ahead and pay for things they do not have to pay for in order to keep their member or a contracted physician/clinic (generally only done with hospitals or multi-physician clinics) happy, or if a reasonable person would expect the insurance company to pay, even if technically they don't have to.

[Deleted]

shanendoah,

I just don't see where filing an appeal will get me, besides more work. I file the appeal, insurer rejects appeal based on the timing of claim submission, costs pushed back on to dentist office, dentist office bills me for costs. I'm back to square one.

Based on the policy posted on their website it appears it is ultimately my responsibility to track claim submissions, payments, etc. The way my dentist office is handling this is bad business, but I don't see what legal recourse I have on my side.

Here is their insurance policy as posted on their website:
"As a courtesy to you, we are happy to handle submission of claims to your primary insurance company and accept payment directly from them. Secondary insurance submission is the responsibility of the patient. Your patient co-pay, including any deductible, is due in full on the day services are rendered. Any amount that is left unpaid by your insurance or is not paid within 60 days by your insurance is your responsibility. You are responsible for monitoring your insurance coverage and payments. In the case of a default, you are responsible for any additional collection charges that may be applied to your account including finance charges (18%) and reasonable attorney’s fees."

[michelyn8]

Any amount that is left unpaid by your insurance or is not paid within 60 days by your insurance is your responsibility.

Read more: notmsnmoney.proboards.com/index.c....0#ixzz1BQ9toJ6I

This implies that they will immediately file the claim. In this instance they did not and cannot prove they did. Send them a certified letter with a timeframe you expect them to provide the information on the filing of the initial claim. Then, I would follow the advice given, file an appeal.

I meant to hit edit but his delete instead. I wanted to add that if they do take you to court, you can ask them then to prove the claim was filed in a timely manner. Since they obviously can't, odds are the judge will dismiss the case. Yes its a hassle but it will feel good to come out on top. Sounds to me like this lady is someone who doesn't like to have a mistake pointed out to her but is also one who never keeps records to cover her ass. She's not going to work with you because she didn't do anything wrong in her mind.

[Deleted]

Jan 18, 2011 14:34:48 GMT -5 zibazinski said:

It feels DAMN good and I'd do it BEFORE you went in to pay your bill. DEMAND your charts as well and don't let them BS you about a fee for doing it. Plus, I'd talk to the dentist.

I found out from my yelp.com search that my dentist won't provide copies of dental records on the spot. They charge $50 in fees to mail them on their own time when they're good and ready to release them.

[zibazinski]

THAT is illegal. Report them to your insurance commission. Those are YOUR records not theirs.

[shanendoah]

You are responsible for monitoring your insurance coverage and payments

But you did monitor your insurance coverage (you know you were covered) and they state they will bill your primary insurer. You can't monitor payments for a bill that hasn't been submitted. Even by their own policy, you are NOT responsible. And remember, you are not making the appeal to the dentist. You are making the appeal to the insurance company. When they deny provider responsibility, the dentist's contract with the insurance company should make it illegal for them to continue billing you.

As for the $50 they want to charge for your own medical records, here's a quote from hhs.gov regarding HIPAA regulations in getting copies of your own medical records.
"The Privacy Rule permits the covered entity to impose reasonable, cost-based fees. The fee may include only the cost of copying (including supplies and labor) and postage, if the patient requests that the copy be mailed."
In other words, if they want to bill you $50, ask for an invoice. The dentist isn't the one copying the records. An office clerk being paid $12/hr is. You shouldn't have to pay more than $0.10/page (or whatever kinkos charges), and the actual cost of mailing, if the records are mailed. (You could pick them up.)

At this point, I would consider contacting your state dental board and making a complaint against the office.

[Deleted]

I don't know much about insurance but I do know HIPPA, Shanendoah is right. That $50 is ridiculous and illegal. I can walk in and say I want my records, they can charge me a small fee but not $50 (unless you have thousands of pages to copy) and it better be timely, as well.

[zibazinski]

I'd start pointing out all these things to your dentist LOUDLY. There's no way they want MORE negative publicity.

[shanendoah]

And I would note that you dentist's office knows full well that it is "easier" to simply pay then to file the appeal through the insurance company or to fight their charges for medical records, and that is what they are counting on.
If, for whatever reason, you feel its better to just pay and move on, do so. Do whatever is best for you.
I just want to make sure you know that you do have options, and what steps you can take to fight this, if you have the energy to do so.

[Deleted]

shanendoah, thanks.

Your insights have been helpful. After a few more calls today, I've convinced the billing person at my dentist office to call the MetLife claim contact number and talk to the insurance people instead of me being the one stuck in the middle wasting all of my time. Metlife says she'll need to take it through the appeals process (as you've already suggested)...just glad I'm not doing it. So we'll see where this goes, but I'm not too optimistic on the outcome. Billing person is still convinced the claim was submitted correctly, and on time, and says this is all the insurance company's fault. So, we'll see what changes, if anything, after she calls MetLife.

[Sharon]

I deal with Metlife with dental billing frequently. I do know that they have 3 separate systems. The have a paper claims system, a real time claims system, and a batch claims system. The real time claims system and batch system deal with electronic claims. Depending on how the provider submitted the claim will depend on whether it went real time or batch. We constantly fight the issue where a patient will be up in one system but not another, or they are set up differently in one of the systems.

This could be an issue where both the insurer and provider are correct. MetLife's real time claim system adjudicates the claims without human intervention. If a claim is submitted into the real time claim system and they can not make a match on the patient. They will reject the claim for "Patient Not on File". The claim never made it into Metlife's system so they will say they never received the claim. If your provider did not see the rejection message they will not know that the claim was rejected. More often than not the providers do not understand the message and do not realize that the claim was never accepted by Metlife.

[mrsgords]

I'd go into the dentist's office in person and ask to speak to the owner/manager. I'd flatly tell them I'm not paying it. Then I'd change dentists.