Is it legal for "in-network" dentist to send me a bill when insurance company denied claim?

Question

A couple months ago I went to the dentist for a crown, he noticed my jaw clicking and he said that I would need a "occlusal adjustment" to help fix this.

Based on what I was told, I was under the impression that my insurance would cover this. I then got a notice from my insurance stating that they need additional information from the dentist before they can approve this claim. My dentist's office assured me that this is part of the process and they would have to send it paperwork so they can approve.

Well my insurance didn't approve it because of the following reason:

Based on the diagnostic materials provided by your dentist, this service does not meet this requirement for coverage. You should not be billed for this service.

The amount billed on my insurance claim shows $500, the member rate shows $319, and if this claim got approved I would have just owed $95.

Today I get a bill in the mail from my dentist at $594 and the receptionist stated that my insurance did not allow any benefits for this procedure so the dentist gave me a ($150) discount so the bill is for $444.

Is this legal, can he send me a bill when he's an "in-network" dentist and my insurance denied his claim?

I would have never done this procedure if my insurance didn't cover it but since they made me believe it was part of the process I thought they had experience with this sort of thing before.

Since my insurance says "You should not be billed for this service.", does that mean he is not allowed to bill me as an "in-network" dentist?

Answer 1

It is legal for a dentist to bill you for services rendered. You have an obligation to pay the dentist (in exchange for services); the insurance company has an obligation to cover certain expenses of yours (in exchange for money); the dentist has an obligation to the insurance company to accept certain terms specified by the insurance company (in exchange for being listed as 'in-network'). Your recourse is to object to the insurance company, since they are the ones who have an obligation to you. The brute force approach would be to sue the insurance company for failing to cover something that they are (ostensibly) obligated to pay on your behalf, under the terms of your insurance contract. However, the chances are virtually non-existent that they are actually obligated to pay the dentist. You can call the insurance company in advance of the procedure and get a definite decision as to whether the service in question is covered, and if they say "Yes", then you are covered, otherwise you will know you are not, and can plan accordingly.

The insurance company has some (minor) leverage over the dentist, if the dentist has breached his contract with the company. If a service provider egregiously breaks the terms of an agreement with the insurance company, the provider could be sued or at least dropped from the in-network list. This is, however, fairly theoretical. The insurance company statement "You should not be billed for this service" has no legal force, but it does weakly suggest that they blame the dentist somewhat (the alternative is to simply say "This service is not covered").

Your obligation to the dentist arises from the service provided plus the rarely-read clause in the financial agreement document that you signed at some point which says something like "We will submit claims to your insurance company, but you are ultimately responsible for any unpaid charges". It is highly unlikely that the dentist actually lied to you about the cost, especially it is unlikely that he said anything that could be construed as a promise that the insurance company would provide a particular level of coverage. For future reference, you either need to get a clear written statement from the service provider that they will accept whatever the insurance company allows you (i.e. their seat of the pants estimates are legally binding), or you need to get a clear written statement from the insurance company regarding what is and is not covered.

Answer 2

Insurance law varies from state to state and policies have widely varying language. What your insurance company is bound to [as it refers to their obligations to you to cover charges] is the language in their contract. Without providing a lot more information, all you can get here is some very general information that may or may not apply.

There are also contracts however between a medical [provider] and the insurance [company]. In order to get "in-network" status, most contracts agree that the provider will accept whatever the company pays for a covered procedure. The provider is obligated to accept this amount and does this so that they will get the referral business from the company. The company wants this because it makes their policy of value because of certainty.

This provision only applies to covered procedures however. If a procedure is NOT covered, then the contract between the provider and the insurance company is likely irrelevant where you are concerned and you are obligated for the entire amount [subject to reasonableness]. The company is not responsible to pay a bill because your provider says so.

This can put patients in a really tough position, and for this reason, many providers will have someone on staff who gets a procedure approved by the company prior to it being done. If that approval is obtained from the company, then the company is obligated to cover it as a procedure. This however, is most usually done by medical doctor's offices, clinics and hospitals as a courtesy to you and to ensure they will be paid, and probably less done by dentists offices. Ultimately, the responsibility to make sure it is approved is on you, not the provider unless the provider's policies flatly say they take responsibility for it.

Very likely, you owe this and don't have much recourse. Call it a life's lesson. There may be a justifiable reliance exception to all this however. If the dentist actually told you that they got it approved or that it was a cost covered by your insurance, then they induced you to do business with them because of a reasonable and justifiable reliance on their statements and experience.

A further point on this is potentially worth noting, and this is a matter of process, not law. The relationship between the provider and company is a tricky one that is not written in stone, yet is covered by very specific medical codes that relate to the health issue or medical complaint. In many cases, it is simply a matter of the provider adjusting the insurance claim submission to make the procedure align with the complaint... in other words, it's miscoded and therefore won't pass through the company's system. Second, I've seen cases where the provider called the company and gave the insurance company's doctor the rationale for doing the procedure. If that doc deems it reasonable, it could get waived through.

A final practical note is to beware of providers who sell you on procedures. Even a covered procedure may not be covered if it isn't prescribed for a specific complaint that you came in with such as pain or irritation. A doctor hearing a sound isn't YOUR complaint. It's his idea. As a side note, I have an ethical issue with doctors who volunteer procedures that aren't medically necessary because it is there merely to bump their profits. Often the patient gets stuck with it as you have. If they are going to do this, I think they have an ethical obligation to inform the patient that they should seek advanced approval from the insurance company before going forward.

Answer 3

Contrary to what the other answers say, it absolutely does matter what you were quoted in advance. Most jurisdictions (for example this one) forbid service providers (of all kinds) to charge more than they quoted. It is common knowledge for people who work in purchasing.

So if, before service, the doctor said non-covered services would be zero, he can't collect anything from you. He absolutely cannot change this amount after you've made a decision, because your decision was indeed based on the quote.

Unfortunately, doctors have difficulty with this concept because business licensing agencies get tired of policing this for doctors specifically. Also doctors are trained in techniques to get people to sign blank-check financial agreements (that are typically not enforceable but still intimidate people).