I recently got dental work done and after he finished, my dentist had me pay a bit extra for an additional bit of work that 'went over my coverage amount' and gave me an itemized statement/receipt showing each charge and the extra I paid. It also showed the amount that was supposedly being submitted to my insurance company. (It's a Medicare Advantage dental plan) When I logged onto my insurance website a few days later I see he padded the charges substantially when submitting the bill to them, going way over my insurance amount. Also, he submitted codes requesting payment for work he didn't do. Is that legal? Should I mention it to my insurance company?
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Here we don't give advice as to what people should do (other than hire a lawyer). You may want to rephrase your question to avoid being closed.– GreendrakeCommented Dec 10, 2023 at 2:25
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1 Answer
This is normal for in-network providers. If you take the time to look at the insurance company's explanation of benefits, you'll find it happens with all providers.
Insurance companies have negotiated rates with each in-network provider. Their contracts may allow or prohibit certain billing items, for example a blood draw fee may already be included with a lab test fee.
Rates and billing policies vary across each insurance contract, so the provider bills the insurance company with the maximum rate, which you saw. The insurance company will process the claim, reducing billed fees to the contractual rates and adjusting items as necessary. You will get an explanation of benefits detailing the adjustment and the allowed amount which will be much more reasonable.
Billed rates practically don't serve any purpose, save to come up with some huge "savings" number on your insurance statement. Even uninsured cash payers will receive a lower cash rate, in line with insurance rates.
With modern billing software and insurance company Internet APIs, the doctor's office knows what they're going to be paid in advance, which is the number that was shared with you. Your provider either extended the negotiated rates to the non-covered work or gave you an uninsured discounted price.
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1Why on Earth would an insurance company agree to pay more than an uninsured patient would have to? Commented Dec 10, 2023 at 8:10
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1@Greendrake because insurance companies’ products are legally limited to a percentage of benefits paid out, essentially.– SneftelCommented Dec 10, 2023 at 13:31
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@Greendrake Insurance claims impose additional costs. For an insured patient, the provider has to code the services done, file a claim, wait a month or so while it's processed and paid, if there's a mistake or dispute, go through adjustment processes, plus the overhead of negotiating rates and contracts, and now insurers are requiring metrics and patient surveys. One provider overcharged my copay, so I got a check in the mail, another attributed my flu shot to a uncovered doctor, so it was free. A cash patient simply receives a cost and is usually required to pay in advance of the services. Commented Dec 10, 2023 at 20:57
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The costs of running insurance business explain why it would rather pay out less, not more than the provider would bill an uninsured patient. It still doesn't make any sense why they would do the opposite. Commented Dec 10, 2023 at 21:21
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@Greendrake In the US, it is not mandatory a provider accept insurance, nor any specific insurer or their network. If an insurer doesn't adequately compensate, the provider will simply drop that network, and subscribers will leave. My employer offers 5 different plans, I'll just choose a better one. You also have to consider that 2/3 of employer health plans are self-insured by the employer, the health plan merely passes along the bill with a markup. Quality of health plans is a major factor in hiring and employee retention, so if a company is stingy with their coverage, employees will quit. Commented Dec 10, 2023 at 21:53