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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?

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    That line honestly looks like a bug in their system - someone accidentally appended that line onto the wrong message. Have you tried just asking the insurance company what was meant by that line? I'm betting they'll tell you it was a mistake or give you some alternate explanation for it. – animuson May 5 '17 at 15:16
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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.

  • "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." That "assurance" may put some liability on the dentist. It might come down to how much the patient reasonably believed was covered. The liability is greater than $95, but might be as little as $444-$119 or $125. – Libra May 6 '17 at 17:57
  • Usually, the office does not "assure" any such thing, they make a statement of what they expect. If there is some record of the exact statement, they might be held to that statement, but not something like "insurance companies usually cover this". – user6726 May 6 '17 at 18:20

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