Complaint Review: Teddy Bear Dental

I always check patient's insurance benefits before the patient comes in for their appointment, especially with new patients. I have more than 10 years of experience in dental front office. This patient's mom called the day before to set up the appointment for her daughter for the next morning. First, I had an automatic response unit from the insurance company fax over the patient's eligibility and benefit. The facsimile was not sent to us until the next morning after patient's appointment time. When I did not receive the fax within 30 minutes, I did called the insurance company and spoke to the representative regarding patient's benefits and history. The rep gave me 100% for preventive coverage information, then. We always get insurance coverage info both verbally over the phone and via fax to minimize discrepancy. The fax came about right after patient was seen, and gave us 80% preventive coverage info. So I told mom right away this discrepancy from insurance company. Is it the front office's fault when the rep at the insurance company gives out the wrong information? Is it fair to call the front office a liar? Any information that we received verbally from the insurance company is not a guarantee that it will be accurate. And, we tell this to all our patients, as done in any professional dental offices.

After the insurance paid, the office did adjust off that 20%, patient's co-pay, which came from the insurance company's mistake. I did not think I was supposed to, because it's not our office's fault. But, it was parent's fault either, I thought. So, I made that adjustment. However, the insurance company denied for examination and bitewing due to limitation. Even though there was no history of bitewings taken, patient's previous dentist took too many intraoral-periapical films so insurance company considered the patient has met her full mouth series. Taking that many x-rays on children is very unusual. Patient's mom was also very surprised that her former dentist took that many x-rays on a six years old child and billed out to the insurance company. Mom told us later that her child went to another dental office after that. According to mom, she paid in cash for those services. Anyway, I would not know why that 2nd dentist billed insurance, when mom says she paid cash for those services. Now, these services denied by insurance company cannot be waived, because it is improper insurance billing practice, if we do. Even insurance makes a disclaimer that there is no guarantee of payment or coverage, because some services rendered by previous dentists may not have been billed out on time or billed out but insurance company may not have entered them into their computer system on time.

In the beginning, patient's parent clearly did not mention anything about the office's coupons. If she did, I would have told her that she cannot combine insurance with coupon, but she can choose to use coupon only as cash patient. However, patient's mom clearly did not mention about the office's advertisement until insurance company denied for those services. We always tell parents that coupons are only applied to cash patients, when they inquire about the coupons. On the coupon, it clearly said call for details. Had that parent mention about the coupon on the appointment day, I would have let her know that she cannot combine both insurance and coupon together, as I always do to everyone. Because that would again be improper billing practice. If she chose to not utilize her insurance, then her kid's dental visit would have been $129, not $89 because there were 2 additional x-rays were taken on that day.

It seems like you are upset because you have to pay the money out of your own pocket. IF your PPO insurance was 100% covered for preventive, I don't know where that dentist would have gotten the figure of $160.00 to charge you. It should be covered by the insurance... and that is the contract between your insurance and "IN NETWORK dentist." There could be a chance that your insurance might not cover 100% (some insurance pays 80% or 60% on diagnostic/preventive) or you might have done more than specified number of cleaning allowed by your insurance...or you went over your maximum allowed per year that the cleaning or some diagnostic procedure was denied. Please check that out with your insurance.

Unless you have delta dental insurance premier, every ppo insurance has fee schedule with in-network dentist. It's not the dentist who charges that much money... instead, it's your insurance company that sets this price and most of times, in net work insurance pays lowers than what dentist normally charges. In your case, it's reversed because your dentist was doing special ad.

For cash patients, dentist can give as much discount as he/she wants and dentist has right to set the price to whatever he/she wants.... just as Best Buy can set the price of computer to $1000.00 and Frys can set the price of same computer to $600.00. So there's no fraud involved.

Here's the simple resolution:

All you had to do was tell the receptionist or manager who collects money not to charge your insurance and pay $89.00 if that was how much you thought it was going to cost. It's your choice to either become cash patient or insurance patient.

Dental office CAN'T charge insurance unless they have written approval from you. Knowing that 99% of dental offices are not too stupid, I am certain you signed one of the forms that states "you allow dental office to charge and collect the money directly from insurance company for procedures done."
For that reason you can't scream insurance fraud because you probably sign the paper and allowed them to charge to your insurance.

In my opinion, by giving you the discount, your dentist is committing insurance fraud because he/she is supposed to collect 100% of the copay especially if he/she is in net work with your insurance. (This is the tactic that insurance company wants, so that you as a patient do not go to the dentist often and all the money that you are paying from your paychecks are kept to insurance company). Which means dentist have to collect $100.00 more from you. IF you report this to your insurance, I think your dentist will probably send you to collection agency to make sure he/she is not committing any fraud --- stating that patient didn't pay full amount of co-pay.

Well, that's how I see it. 3 solutions:

1) You can either pay $29.00 more to your dentist and tell your dentist to reverse the insurance charge (which won't do you any good because your 2008 insurance period probably ended on dec 31st of 2008 but you can screw dentist by having he/she pay back insurance by $150.00) ---> makes your insurance company happy and you get mental redemption.

2) You can call insurance company and make the deal bigger by saying your dentist doesn't accept full co-pay. ( then this will trigger insurance audit on your dentist and if dentist did accept all the copay from other patients within your insurance, they will probably let the dentist go and you will be getting a call from either your dentist or collection agency for "not paid copay")

3) You can calm down and start looking at yourself for what you've caused. You and your dentist are both committing insurance fraud because it's your obligation too to pay full copay/deductable when you use your insurance too and your dentist is supposed to collect your copay/deductable.

If this dentist is in network for your insurance company or network, they have signed an agreement to not charge any more than their reduce fee schedule. If they charge less, then they have to charge that amount. If your insurance covers 100% of preventitive this should be a non issue. If they were not in network with your insurance company then they got you in their office fraudulently. That should be reported to the attorney generals office of your state, consumer affairs for your state and the state dental bar association. $310 is a lot for a first examination, full mouth x-rays and cleaning even if they charged their usual customary fees. I would report the complaint to your insurance company. If there are restrictions on their offer, it should say it on the coupon. Good luck!