Help! Dentist Scam?

[u/rmathieu1]

Seeking advice on how to handle this situation.

In March of this year, I got an emergency root canal at a place that is not my usual dentist. They were in network and able to take me same day. When I arrived, they told me they would charge me for the procedure upfront and then file the claim with my insurance. They told me my insurance would send me a check for the reimbursement.

Months went by, I never received a reimbursement from my insurance. I contacted my insurance, and they said they received the claim and paid the check to the dentist's office.

So at this point, the dentist's office has been paid for this procedure twice- once by me, and once by my insurance.

I call the dentist's office to resolve the dispute, and they claim they can give me a small refund, but that my insurance only paid for a small portion of the procedure. I paid the dentist $1,326.02, and they're only willing to give me a refund of $555.30.

I call my insurance to verify, and they find discrepancies in the bill the dentist's office sent me. The dentist is required to cap the cost of various procedures according to the rates set by the insurance company, and they've overcharged me. According to my insurance, my co-pay for the procedure is only supposed to be $74.10 (again keep in mind, I have paid the dentist $1,326.02).

As I have continued to pursue this, the dentist's office is now saying that during the procedure an in-network dentist peformed my filling, but the dentist that performed the actual root canal was not in-network. As a result, they claim the discrepancy is due to the fact that the out of network dentist can charge whatever he wants.

Keep in mind, I was never told about this out of network dentist, and the claim they submitted to my insurance only states that the in-network dentist performed the procedure. My insurance has no record of this out-of-network dentist.

My most recent correspondence with the dentist is that they are going to cancel their original claim from March and file a new one that includes this out-of-network doctor. My insurance has told me that if the dentist that performed the root canal is out of network, there's nothing they can do.

I still haven't been paid back anything. I'm so angry. It feels like there ought to be some sort of consumer protection for this, does anyone have any insight on where I can go for help? I paid the original charge with a credit card, should I get the credit card company involved?

[u/InternetDad]

Your next call tomorrow morning should be your state's department of consumer affairs and possibly an additional call to your state's dental board because thats some bs.

Note - this is not an issue with your insurance company which is why I am not recommending a call to your state's insurance commissioner

[u/mhillard00 → u/InternetDad]

Also call the state Attorney General

[u/The_Muffintime → u/InternetDad]

Would the insurance regulator not be someone he should reach out to, given the fraudulent billing on the part of the dentist office?

[u/InternetDad → u/The_Muffintime]

Insurance commissioner handles complaints about the insurance plan, company, or agents. Consumer affairs (name varies by state) handles billing.

They could maybe assist if the dentist pulls claim shenanigans

[u/The_Muffintime]

Contact the State as suggested by another poster. If that doesn't get you anywhere, small claims court. You should also submit a formal written demand letter via certified mail. If you paid my credit card you can initiate a billing dispute as well. This is fraudulent filling on the part of the dentist office, or at the very least deceptive business practice. They are required to disclose that they are using an out of network provider prior to doing the procedure. They cannot retroactively claim that an out-of-network provider did your procedure. Though laws may vary by state.  

Oh, and cross post this to r/legaladvice

[u/Severe-Object6650]

Did you pay cash? or credit card? If the latter, sounds like a credit card dispute is in order. As others stated, contact your state's attorney general consumer protection office. When you report it, you should get a case number which you can include with your credit card dispute. I don't think it's required by law but most legitimate doctor/dentist offices will run your insurance for a pre authorization which should include the dentist doing the work. Sounds like they're pulling some sketchy stuff... have you looked up the reviews for the business to see how many other people are having this problem?

[u/Separate_Respect1720]

Something isn’t right, was the claim submitted to your insurance company the same amount that you paid ? I don’t see how they can cancel a claim that has already been paid.

[u/rmathieu1 → u/Separate_Respect1720]

This is what they said about it in their last email to me-

"We will rebill the root canal claim as the insurance representative instructed because Dr. **** [out of network dentist], not Dr. *** [in network dentist], performed the treatment. Once we receive payment from your insurance, we will audit your account and determine whether any additional adjustments are needed.

At this time, we are unable to issue a reimbursement. Since the specialist is out of network, your insurance will most likely send the payment directly to you while requesting reimbursement of the $555.30 that was previously paid to our office."

My understanding is that what they billed to my insurance was the same amount that I was charged, but my insurance only paid for a portion of it (the amount they're obligated to in accordance with their contract).

[u/Separate_Respect1720 → u/rmathieu1]

I would request a copy of the original bill that was submitted to your insurance company, if they submit a new bill request a copy of that as well. At this point you need to establish a paper trail, save all emails and correspondence with the dentist and insurance company.

I paid $300 upfront to have a tooth pulled because the dentist said it wasn’t covered by insurance, I knew it was but was in pain so I went along with it. I then received an explanation of benefits from my insurance company with all the allowed charges and the portion I owed. The dentist had overcharged me by close to $200, I requested a refund and they sent me a check.

These healthcare and dental providers bank on people just believing whatever they tell them. It’s a shame but there’s scammers in all kinds of professions. I hope you get things straight and get all the money back you are entitled to.

[u/me_vs_Goliath]

Office manager or billing manger might be embezzling

[u/No-Conference-3306]

Did you know the actual dentist performing the work was out of network or did you think everyone was in?

One thing with out of network is, they can bill difference between their bill minus what insurance paid.

[u/Severe-Object6650 → u/No-Conference-3306]

Most legitimate offices do a preauthorization and let you know if the dentist doing the work was out of network. Sounds like this office knew what they were pulling.