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CalAttorney2
CalAttorney2, Lawyer
Category: Consumer Protection Law
Satisfied Customers: 10238
Experience:  I am a civil litigation attorney representing individuals and businesses.
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I had to do some dental procedures (root canal and crown)

Customer Question

I had to do some dental procedures (root canal and crown) for one problem tooth back in August and I was told that it would cost me $1970.6 that then I could claim to my insurance company in order to get reimbursement. So I paid $1970.6 to the Dentist
that time. So the explanation of dental benefits showed that the insurance company would cover about $1000 and my responsibility was $980. However last month I found the dentist started sending claims to my insurance company to get paid as well, however for
amounts significantly different than even I paid them. Right now the total billed amount is $5066 instead!!! I requested Dental office to provide me with the receipt for all dental procedures were done for me that time. The receipt statement shows $3780 as
a total for all dental procedures were done that time. So the actual receipt and claims they sent to the insurance company don’t match and are different in term of amount for the same dental procedures. Also I found that they added two Unspecified Diagnostic
Procedures for total $1400 as $750 and $650 amounts accordingly. I called Dental office and they refused to provide any explanation or specific information regarding Unspecified Diagnostic Procedures for $1400… Right now I’m in the situation when dental’s
claims show much bigger amounts they want me to pay. The insurance company told me that this issue should be resolved between Dental company and me, so the insurance company can do nothing. At this point I see the following: 1. Billing for services were not
provided (fraud?); 2. Dentist did not report to insurance company regarding any payment I did already 3. Dentist submitted claims to insurance that are different from the receipt (insurance fraud?) Any advice how to deal with the Dental in this situation will
be appreciated.
Submitted: 1 year ago.
Category: Consumer Protection Law
Customer: replied 1 year ago.
I had to do some dental procedures (root canal and crown) for one problem tooth back in August, 2015 and I was told by the Dentist that it would cost me $1970.6 total and then I could claim this amount to my insurance company in order to get reimbursement. So I paid $1970.6 to the Dentist that time.In September I received an explanation of dental benefits (EDB) showed that the insurance company would cover about $1000 and my responsibility was $980.However last month I found the dentist started sending claims to my insurance company to get paid as well, however for amounts significantly different than even I paid them already. Right now the total billed amount is $5066 for one crown!!!I requested Dental office to provide me with the receipt for all dental procedures were done for me that time. The receipt statement shows $3780 as a total amount for all dental procedures were done that time. So the actual receipt I received from Dental office and claims they sent to the insurance company don’t match and are different in term of amount for the same dental procedures. Also I found that they added two “Unspecified Diagnostic Procedures” for total $1400 as $750 and $650 amounts accordingly. I called Dental office to get clarification on this and they refused to provide any explanation or specific information regarding Unspecified Diagnostic Procedures for $1400…Right now I’m in the situation when dental’s claims show much bigger amounts they want me to pay. The insurance company told me that this issue should be resolved between Dental company and me, so the insurance company can do nothing.At this point I see the following:1. Billing for services were not provided (fraud?);
2. Dentist did not report to insurance company regarding any payment I did already
3. Dentist submitted claims to insurance that are different from the receipt (insurance fraud?)
4. I will not be able to get my $1000 as reimbursement I paid to the Dental officeAny advice how to deal with the Dental in this situation will be appreciated.
Expert:  CalAttorney2 replied 1 year ago.

Dear Customer,

This is a billing dispute (complaint over applicability of charges). There is a series of escalating things you can do to deal with this situation. (I understand that some of these things are things you have already done, but I am listing them all so that you have a complete list and they make sense as a whole). As this type of billing does appear fraudulent as opposed to simply negligent, I would recommend following up with the report to your state's attorney general as noted below (in addition to the other items).

  • *First: start with the company's customer service and dispute the claim. Keep your complaint in writing. If you speak to someone by phone, follow up promptly with a "confirmation letter" (see my note below).
  • *Second: (you can do this at the same time), if you paid by credit card (not debit card) you can open a dispute with your credit card carrier (follow the instructions with your credit card company). (Some banks do allow for charge disputes on your debit card - but not all, the laws are not the same and debit card purchases do not have the same protections, if you paid by debit card, contact your bank and see if they do have dispute resolution remedies).
  • *Third: open a dispute with the BBB. The BBB offers consumer dispute resolution that is fast, free to consumers, and is usually effective, they have no enforcement authority, but all BBB disputes result in a public report regarding resolution so businesses do respond to them. You can open a BBB dispute here: bbb.org/consumer-complaints/file-a-complaint/get-started
  • *Fourth: if you believe that the company is acting fraudulently (not just charging high rates), you can report them to the state Attorney General. The AG's office does not prosecute individual claims (so they will not get your money back for you), but they will investigate and potentially take administrative and/or criminal action against the company.
  • *Finally: you can file a small claims action against them for breach of contract. Small claims actions take approximately 3-8 months to go to trial. There is no guarantee of success in these disputes, but filing a small claims action does open an opportunity to negotiate a resolution (in addition to the above opportunities and can lead to mediation - many courts offer mediation programs for their small claims docket).

Confirmation letters: Keep written records of all communications - so if you speak to someone by phone, promptly send a follow up "confirmation letter" summarizing your conversation, who you spoke to, when, and any agreements you reached. Keep copies of your outgoing correspondence, as well as anything that you receive.

I wish you the best of luck with this dispute, and hopefully a speedy resolution.

Customer: replied 1 year ago.
William,I appreciate your quick response on this. However here is a few questions I got in order to follow up your advice:1. Regarding the option to dispute with my credit card carrier - I'm pretty sure this action can hurt me since they can give the case to collectors, so my credit score will drop etc. Or they can provide my bank with some evidence such as my signature on the receipt I did for that transactions, so the bank will not dispute those transactions then.2. Should I inform in any way the Dentist that I'm about to take legal actions against them?3. Can I resubmit the claim based on a receipt I got that time from the Dentist in order to get reimbursement even I can see the Dentist submitted claims as well?Thank you,
Expert:  CalAttorney2 replied 1 year ago.

You can use your credit card carrier as a way to dispute the charge. This does not automatically create a "bad debt" it simply gives you an opportunity to negotiate a resolution using the credit card company as an intermediary (with some leverage).

You do not have to inform the dentist ahead of time.

You can contact your insurance carrier again, but based on what you have posted they are already aware of the dentist's double billing practices. You probably should document your communications with the carrier, and even follow up with them again, but don't count on them to resolve your dispute for you.

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