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The patient is given a quote for a crown total of $900.00.
The patient paid the deductible and her quoted portion of $450.00 up front. When the patient received an EOB from the insurance $1600.00 had been charged to the insurance for the same crown. When questioning the amount, the office manager stated that he can charge any amount he wants to the insurance company. The doctor stated that the billing is out of her hands. The insurance company states that the patient should not have gone out of network and it is out of their hands. IS THIS LEGAL? OR THIS INSURANCE FRAUD? Not only was the bill to insurance excessive but it also used up $700.00 more of the patients yearly maximum than originally quoted which means she will not be able to complete other dental treatment needed.

  • I am not downvoting (or VTC) your question, but in its current form it is unanswerable because it is confusing and relevant pieces of information are missing: What is your jurisdiction? whose "office manager" you mean (I presume you mean the dental care provider, but could be otherwise)? what does EOB mean (perhaps Estimate of Billing?)? Most important, one will need to look at your insurance policy and any associated contracts (whether entered with the insurer or with the provider) to make sense of the deductible(s), policy limit, claims procedure, any co-insurance, and so forth. – Iñaki Viggers Mar 27 '19 at 10:04
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    @IñakiViggers EOB means explanation of benefits. It is a report that a health or dental insurer is require to provide usually monthly in months that have any activity that shows the provider's invoiced price, the insurance company allowed amount per the agreement between the provider and the insurance company (if there is one) and per insurance company policy for out of network providers if there is not, and the insured patient's share of the provider's charges that the insured is required to pay if the provider does't bill for the charges disallowed by the insurance company for each line item – ohwilleke Mar 27 '19 at 18:34
  • @ohwilleke Thanks for clarifying. That makes sense (my guess of "Estimate of Billing" did sound weird to begin with). – Iñaki Viggers Mar 27 '19 at 18:44
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Dental "quotes" are typically estimates of a patient's financial responsibility, given the insurance information provided by the patient. If you patronize an in-network practicioner, it is fairly easy for them to be pretty accurate in that estimate, but there can be some small errors when it turns out the insurance company thinks one thing and the doctor thinks something else (the doctor generally loses). This is because an in-network provider has a contract with the insurance company that says what they can charge and what they will receive. They could charge the patient more than the maximum allowed by the insurance company, but that would be a violation of their contract with the insurance company. It is very common that a doctor bills for a large sum, accepts much less than that and passes on a specific amount to the patient as their responsibility.

An out-of-network provider doesn't have those limits on what they can charge, also they may be less accurate in estimating patient responsibility. Indeed, an out-of-network provider could simply hand the patient a bill and a receipt, leaving it to the patient to get reimbursed, especially if the insurance company is a known pain in the neck. Insurance companies encourage you to patronize in-network by (1) limiting what the doctor can charge, (2) paying a greater portion of the bill, (3) having separate in-network vs. out-of-network yearly maxima plus often higher out-of-network maxima.

The doctor can charge any amount he wants to the insurance company, in any event – the insurance company is responsible for deciding what they will pay (a doctor can symbolically overcharge and accept lower levels of payment, if he wants to). So, yes, this is all legal. It's all part of general contract law, regarding the three contratual relations you+insurance, you+doctor and doctor+insurance.

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    Without reading the "quote" document, it is hard to know whether it was merely an estimate, or if it was an agreement to a contractual price. While the former is likely, it isn't really possible to tell on the face of the question. Also, to the extent that there was no an agreement on price, there is arguably not contract formation and the dentist may be limited to recovery for the fair market value of his work in quantum meriut. – ohwilleke Mar 27 '19 at 21:43
  • Clarification: If this particular dentist is out of network, then there is no doctor+insurance contract. At most, the patient has “assigned her benefits” to the doctor or clinic. – Damila Feb 27 at 5:11
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If you are not in network than no it is not fraud and they can do that. It is only fraud if you use and in network dentist that is CONTRACTED with your insurance company. In the dental and insurance contract your insurance can only be billed for the agreed upon amount in the contract between the dentist and insurance company. Say they want to charge you 257 but the contracted amount between the dentist and insurance is only 197 then they can only bill your insurance for 197 then your plan wether it be good or bad pays its portion and whatever is left will be in the patients responsibility box on your Explanation of benefits. However if the dentist goes through the insurance and then sends you a bill for higher than what insurance says is your portion of the payment to the dentist is THEN it is fraud and is illegal because they cannot charge or make up the difference of that contracted amount because they are in a binding contract.

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