Dental insurance overpayment

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Dec 13, 2018
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#1
Hello all, please advise. I took my daughter to a dentist for a referral for wisdom teeth extract ion. After deciding to persuade, I was told that they don’t work with secondary insurance so I would be required to pay the difference between the amount the insurance covered and the provider’s charge . However, they would assist me by helping with the claim from my secondary but they couldn’t promised a refund and I would have to follow up with the secondary and all correspondence will be sent to me directly.

I paid what was required, $555, and the extractions were done. The claim was then submitted to the secondary like promised. After some time, I got an EOB from the secondary stating that $1341 was paid to the dentist, however I was only refunded $555, which is the amount I paid out of pocket. I spoke to the secondary and they stated that the entire amount should be sent to me. The dental office however refuse to issue the refund.

I feel as though the provider’s charge was paid in full between the primary insurance and my out of pocket (as I was told prior to agreeing to get the extractions done.)Therefore, they shouldn’t have anything to do with the check that came from the secondary so either I should be refunded the entire amount on the check or I portion should go back to the insurance after my out of pocket amount is refunded. I want to know if there is any legal recourse or should I leave it alone?

Thank you
 

Neil Maley

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Dec 27, 2014
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#2
What was the full amount the dentist charged for the extraction? You paid the difference of $555 of what the true cost was less what your insurance covered. If the dentists full fee was say, $1500, and the insurance paid him that - then you should only receive your $555 back.

We can't comment without seeing the actual bill.
 
Likes: jsn55
Dec 13, 2018
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#3
Thanks for your speedy response.

The allowable amount from the primary was $1657 of which they paid $1125 and I paid the remaining $555.

However, the secondary sent them a check for $1341.
 

Neil Maley

Moderator
Staff Member
Advocate
Dec 27, 2014
15,255
14,020
113
New York
www.promalvacations.com
#4
You should notify the secondary that they overpaid the dentist. He needs to send them the money back, only owes you your $555. Thats all he owes you. But I'd call the secondary and find out why they paid him so much - they should be taking the overpayment back from him. No one should be paid back more than the service cost. No one is supposed to be making money off of an insurance payment. The secondary made an error in the amount they sent.

You can report him to the American Dental Society
 
Sep 19, 2015
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#5
What was the total amount billed? How does your insurance work? What was the total bill? Does the provider have to accept the lower payment.

You say you were reimbursed the $555. That is what you paid. Why would someone tell you that you should be paid the entire secondary of $1,341 when your out of pocket cost was $555? That makes no sense.
 
Apr 10, 2017
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#6
You should notify the secondary that they overpaid the dentist. He needs to send them the money back, only owes you your $555. Thats all he owes you. But I'd call the secondary and find out why they paid him so much - they should be taking the overpayment back from him. No one should be paid back more than the service cost. No one is supposed to be making money off of an insurance payment. The secondary made an error in the amount they sent.

You can report him to the American Dental Society
I think you meant the American Dental Association and it's not a governing body in any way. That would be the state dental board. Marsha, you should contact the secondary insurance company and let them know how your primary insurance paid. It's possible they have already gotten their money back from this doctor but you need to make sure they are aware of the additional payment.
 
Likes: jsn55
Apr 10, 2017
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#7
What was the total amount billed? How does your insurance work? What was the total bill? Does the provider have to accept the lower payment.

You say you were reimbursed the $555. That is what you paid. Why would someone tell you that you should be paid the entire secondary of $1,341 when your out of pocket cost was $555? That makes no sense.
That's a good point. It's possible this oral surgeon was out of network for Marsha's insurance, in which case the fee would be higher.

If she did somehow get that $1,341 for herself the insurance company would expect it back from her and rightfully so. Otherwise that would be insurance fraud.
 
Sep 19, 2015
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#8
I have a dr that is out of network and that was what I was thinking.

A patient is not supposed to profit from the experience, but to be made whole financially. As the OP was reimbursed the $555 out of pocket expenses so it sounds as if the dentist did reimburse for the copay (or whatever the term used was by the insurance company) and the OP is not out of any money. The OP is not supposed to profit from the insurance payout. If the dentist was overpaid the extra money would go to the insurance company as it was their money that overpaid.
 
Likes: Neil Maley
Dec 13, 2018
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#11
I think you meant the American Dental Association and it's not a governing body in any way. That would be the state dental board. Marsha, you should contact the secondary insurance company and let them know how your primary insurance paid. It's possible they have already gotten their money back from this doctor but you need to make sure they are aware of the additional payment.
The insurance company was not aware of the overpayment. I did call and notify them twice. Both representative sounded very nonchalant and stated that they don’t coordinate benefits.
 
Sep 19, 2015
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#13
The insurance company was not aware of the overpayment. I did call and notify them twice. Both representative sounded very nonchalant and stated that they don’t coordinate benefits.
Rather than call, perhaps put it in writing and send it to the insurance company.

There are audits from insurance companies -- it may be months later, but it happens, and then they go after the recipient. Better to write a letter to the insurance company and let them deal with it with the provider.
 
Jul 7, 2018
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#15
Can I ask what insurance companies you have that are paying these claims? Primary ? and Secondary ? Having worked in the dental field for over 35 years this is illegal but it happens. I don't know why the dental office would not file the secondary claim as most dental software is programmed to do them. Without seeing the actual benefit policy and how each pays as primary and secondary it's hard to know who gets the overpayment. I would ask for a print out of your account ledger. Then you might be able to see how the dental office applied the payments and how the overpayment was accounted for in their system. You might report it to the state insurance commission but a lot of benefit programs are not actually regulated by the insurance commission.
 

Neil Maley

Moderator
Staff Member
Advocate
Dec 27, 2014
15,255
14,020
113
New York
www.promalvacations.com
#17
Can I ask what insurance companies you have that are paying these claims? Primary ? and Secondary ? Having worked in the dental field for over 35 years this is illegal but it happens. I don't know why the dental office would not file the secondary claim as most dental software is programmed to do them. Without seeing the actual benefit policy and how each pays as primary and secondary it's hard to know who gets the overpayment. I would ask for a print out of your account ledger. Then you might be able to see how the dental office applied the payments and how the overpayment was accounted for in their system. You might report it to the state insurance commission but a lot of benefit programs are not actually regulated by the insurance commission.
Just remember if they were improperly paid and the insurance company claws back, you will have to repay the deductible they refunded you.
 
Oct 13, 2015
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#18
I can't find any mention of how long ago this appointment was but if it's recent I'd suggest verifying that the dentist has actually received the check before doing anything else. I'm an optometrist and had a few cases where patients came with their EOB's, upset that we got paid and were keeping the money. We had to explain that sometimes they get their EOB's before we get the check.
 

Neil Maley

Moderator
Staff Member
Advocate
Dec 27, 2014
15,255
14,020
113
New York
www.promalvacations.com
#19
I can't find any mention of how long ago this appointment was but if it's recent I'd suggest verifying that the dentist has actually received the check before doing anything else. I'm an optometrist and had a few cases where patients came with their EOB's, upset that we got paid and were keeping the money. We had to explain that sometimes they get their EOB's before we get the check.
She says she she was refunded the $555 so I would think they were paid already.
 
Likes: krisseye