Dental clinic over billing insurance claim (credit, college, cost of)

[jk2003]

I recently had a teeth cleaning performed at a dental clinic. I paid 50 percentage out of pocket after the insurance coverage. Few weeks later I looked up the insurance website and turned out The clinic overbilled the insurance company and now I owe another $150 more to the clinic. Called the clinic front office to clarify. Their response was ‘The insurance processed the claim under the wrong physician’. Probably the other physicians rate was higher than the one who attended me. But how does insurance know about the second physician unless the clinic submitted the claim with the wrong information Thereby over billing? I wouldn’t have found this out unless I checked the website. My invoice clearly doesn’t match the rate submitted to the insurance by the clinic.

Is this a honest clerical mistake or insurance fraud? The clinic said they will resubmit the claim with the right numbers now that they know I’m aware of this.

I looked up their website and both the physicians graduated the same year from college. So how can the rates be different?

[escanlan]

Originally Posted by jk2003

I recently had a teeth cleaning performed at a dental clinic. I paid 50 percentage out of pocket after the insurance coverage. Few weeks later I looked up the insurance website and turned out The clinic overbilled the insurance company and now I owe another $150 more to the clinic. Called the clinic front office to clarify. Their response was ‘The insurance processed the claim under the wrong physician’. Probably the other physicians rate was higher than the one who attended me. But how does insurance know about the second physician unless the clinic submitted the claim with the wrong information Thereby over billing? I wouldn’t have found this out unless I checked the website. My invoice clearly doesn’t match the rate submitted to the insurance by the clinic.

Is this a honest clerical mistake or insurance fraud? The clinic said they will resubmit the claim with the right numbers now that they know I’m aware of this.

I looked up their website and both the physicians graduated the same year from college. So how can the rates be different?

Interesting that you bring this up. First how can the rates be different question. Obviously either can charge what they deem appropriate for their services but what matters is the insurance company's "Contracted Rate". You would think that the "Contracted Rate" would be the same from Dentist to Dentist under the same insurance company, including in those large dental operations, but that is not the case. For various reasons and various methods these can easily vary. This was actually explained to me, with examples, by a Doctor I know.



On the question of billing under the wrong Dentist that can easily occur in error without any intention at all of fraud by the Dentist. So many scenarios how that can occur so it is something that can take pages to go through the "What If's". The error can also be caused on the insurance company side again without obvious intentions of causing an issue. One very real possibility is when the claim was processed there was a manual component to it and the processor just used one Dentist name over another by selecting from a drop down list associated with that office. Yes you would hope in our age of technology there would not be a manual component but you would be surprised what happens behind the scenes.


The important point is that you did check the claims process and noted the error. Everyone should check their claims process no matter if a suspected error or negative condition is perceived to have happened. Patients should do this not only to ensure all services are billed and none come back as a surprise later but also to ensure no services were billed that did not occur. For example you go in for a routine sneezes and sniffles issue and see they are billing for X-Rays or some other unrelated action. Insurance companies do not generally tell you when a claim is made and what claim has been made. If a Doctor decides to bill an insurance company for non-performed services just to collect what the insurance company gives and the Doctor obviously not notify you of the difference then fraud may well be occurring. Fraud is what drives up the cost of health care and by extension your premiums.

[Seguinite]

Originally Posted by jk2003

I recently had a teeth cleaning performed at a dental clinic. I paid 50 percentage out of pocket after the insurance coverage. Few weeks later I looked up the insurance website and turned out The clinic overbilled the insurance company and now I owe another $150 more to the clinic. Called the clinic front office to clarify. Their response was ‘The insurance processed the claim under the wrong physician’. Probably the other physicians rate was higher than the one who attended me. But how does insurance know about the second physician unless the clinic submitted the claim with the wrong information Thereby over billing? I wouldn’t have found this out unless I checked the website. My invoice clearly doesn’t match the rate submitted to the insurance by the clinic.

Is this a honest clerical mistake or insurance fraud? The clinic said they will resubmit the claim with the right numbers now that they know I’m aware of this.

I looked up their website and both the physicians graduated the same year from college. So how can the rates be different?

That sounds like somebody miscoded something on the claim. Likely an innocent mistake. But as noted, definitely check the statements. There's a whole lot of 'complicated' in the system.

[nitynity]

Typo happens all the time. For instance if you submit the wrong code, it's a totally different procedure.

[jk2003]

The other Physician is out of network and hence not fully covered by the insurance. So there is a difference in the payment which I will have to cover. My appointment was with an in network physician but they filed the claim under an out of network person. Now they will have to refund the difference to the insurance.

[jk2003]

Now this is getting interesting. They are offering me a credit for the difference than resubmitting the claim. Turned out they already got paid from the insurance (out of network rate) which is higher than in-network discounted rate. But they won't charge my portion of the difference instead give me a credit. (like a store credit towards my next appointment?lol)


That's a sneaky way to charge the insurance extra for regular rate (using non network providers against the patient's knowledge or consent) and use the amount to bribe clients to come back for more business. It's Win-Win. And they have 5 star reviews everywhere. Now wondering if it was really an honest mistake? Contacted the insurance and according to them, the clinic submitted the wrong info and not a typo from their side, which makes total sense because they won't have the out of network provider info in their system to begin with.


If it was really an honest mistake, they wouldn't be offering a credit instead of doing the right thing.

[escanlan]

Originally Posted by jk2003

Now this is getting interesting. They are offering me a credit for the difference than resubmitting the claim. Turned out they already got paid from the insurance (out of network rate) which is higher than in-network discounted rate. But they won't charge my portion of the difference instead give me a credit. (like a store credit towards my next appointment?lol)


That's a sneaky way to charge the insurance extra for regular rate (using non network providers against the patient's knowledge or consent) and use the amount to bribe clients to come back for more business. It's Win-Win. And they have 5 star reviews everywhere. Now wondering if it was really an honest mistake? Contacted the insurance and according to them, the clinic submitted the wrong info and not a typo from their side, which makes total sense because they won't have the out of network provider info in their system to begin with.


If it was really an honest mistake, they wouldn't be offering a credit instead of doing the right thing.

From a practical standpoint of the Dental practice it is easier to offer the credit than resubmit all the paperwork. From your description they may be doing you a favor.

[jk2003]

Originally Posted by escanlan

From a practical standpoint of the Dental practice it is easier to offer the credit than resubmit all the paperwork. From your description they may be doing you a favor.

It’s definitely beneficial for me because it’s not my money. That’s the reason they should be refunding it to the insurance than offer me a credit. And I don’t think the insurance will approve this as well if they come to know I accepted that credit. I don’t wanna end up in any insurance fraud lawsuit in the future. Lol