Dental/Medical Bill advice - insurance sent charges that provider did not disclose

Question

A couple months ago I had some dental work done with dental insurance I had through my job.

After talking to the doctor and being advised to receive some fillers, I talked to the front desk and they disclosed to me the price I would have to pay after the insurance covered all of the costs, it was $350. They did not show me how this was calculated, and I was not told about the total cost before insurance. I was only concerned with how much I would have to pay at the time. I also asked if this was all I would have to pay and there would be no additional charges. They ran my insurance information and told me this is all I would have to pay.

That was ok with me and I proceeded to get dental work done.

For the next few months, I have been weekly receiving an "explanation of charges" letter, saying that I have a "Patient Responsibility" of $1200, and specifically saying "This is not a bill."

I called the insurance company, they were not much help in explaining anything, but they did tell me that charge was a difference between what I was charged and what the maximum insurance would cover.

This made no sense to me, as I previously understood insurance guarantees an "Out of Pocket" maximum, not a maximum of what they would cover.

If this is really the case, and if anyone has had experience with these situations, what advice would you offer in disputing these charges?

Would this affect my credit rating if I wait?

Is this something to take to small claims? What information should I gather in order to do this?

Is there a way to make this a dispute/claim between the provider and the insurance company without my involvement?

In my defense I was given either falsified or misleading information about the charges by the provider and I was charged for something I did not agree to. Would this qualify as a small claims defense, is there a better way to put this into legal terms?

Answer 1

Patients are typically not aware that they have agreed to pay charges, since this is covered once in a flurry of paperwork the first time you see the provider, and one typically does not read all of that stuff. The provider would be able to give you a copy of the form you signed, where it says somewhere that you are ultimately responsible for paying the bill, and that if the insurance company pulls the rug out from underneath you, as it were, you still have to pay.

Assuming the dentist is "in-network", that means that the dentist has agreed to bill the insurance company first, and has agreed to accept some amount less than the total (e.g. if the dentist's bill is $1200 the allowable may be capped at $1000, and then $350 of that would be paid by you, the remainder being paid by the insurance company – if all goes well). The dentist can only make a good-faith estimate of what the insurance company will actually pay. If the insurance company fails to cover an amount that they are contractually obligated to pay, you would be responsible for the rest and you would have to sue the insurance company for their breach of contract. (Unless of course it wasn't a breach and there was some aspect of the treatment that wasn't actually covered).

Insurance companies can take a long time to deal with the paperwork, so waiting is normal. (I've had charges take 18 months to process: 90 days is pretty typical). There is a point, determined by the dentist, at which they may require payment. Usually, they let you know that the insurance company is being jerks, so when you get bills from the dentist that say PAST DUE FOR 60 DAYS PAY NOW OR ELSE, then you either pay up, or they will turn the matter over to a collection agency, and that will affect your credit rating.

If when all is said and done the insurance company refuses to pay some amount for a foreseeable reason (e.g. "gold fillings are categorically disallowed") and the dentist's office was irresponsible in attempting to compute your charges (they ignored that information), then you might have a slim chance of making a legal argument.