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Maverick
Maverick, Attorney
Category: Legal
Satisfied Customers: 6392
Experience:  20 years experience as a civil trial and appellate lawyer
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I recently had to terminate my orthodontics treatment

Customer Question

I recently had to terminate my orthodontics treatment because I relocated out of state.
I started treatment on 9/30/2014 and was informed that the cost of the treatment would be $5,895 for 24 months. I informed the office around 10/15/2015 that I would be terminating my treatment and transferring it to a different orthodontist.
The total that was paid to my orthodontist was:
Delta Dental (Primary): $772.50
MetLife (employer changed insurance on 01/01/2015): $891
Cigna (personal policy): $1,000
Out of pocket from me: $2,407
Total: $5,070.50
I recently spoke with Delta Dental which was the primary insurance when treatment started and this orthodontist is an in-network provider and I was informed that the contracted rate for 24 months of treatment was actually $4,326 (plus $400 for a cosmetic add-on of $4,726 total) although I was never informed of such a thing by my orthodontist. The cost breakdown was $1,081.50 for the initial visit and $463.50 per quarter of treatment after the initial visit of which the insurance would pay 50%.
I have contacted the office multiple times now to get the financials and all i've been told is that I don't owe them any money but that I have $0 credit. How can that be? I terminated the treatment 13 months in (out of 24) and the total cost was supposed to get $4,726 per their contract with Delta Dental yet they received a total of $5,070.50 between all my insurance payments and what they received from me personally.
Am I just out of luck or can I file a complaint with the American Dental Association and/or Better Business Bureau or other agency & trade group? Also, would it be best to go directly to an attorney and have a letter sent?
Thank you
Submitted: 1 year ago.
Category: Legal
Expert:  Maverick replied 1 year ago.

Welcome to Just Answer (“JA”)! My name is Maverick. Please note that:

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Answer will follow in the pane below as per above parameters….

I have contacted the office multiple times now to get the financials and all i've been told is that I don't owe them any money but that I have $0 credit.

1. Send them a letter via certified mail so you have proof of delivery. You have a right under HIPAA to access all of your medical and billing records to make sure that they calculated your balance due correctly. An individual’s right of access generally applies to the information that exists within a covered entity’s designated record set(s), including: (1) a health care provider’s medical and billing records, (2) a health plan’s enrollment, payment, claims adjudication, and case or medical management record systems, and (3) any information used, in whole or in part, by or for the covered entity to make decisions about individuals. A record is any item, collection, or grouping of information that includes PHI and is maintained, collected, used, or disseminated by or for the covered entity. See 45 C.F.R. § 164.501 (definition of “designated record set”). The Privacy Rule requires covered entities to respond to requests for access in a timely manner. Except as otherwise specified, the Privacy Rule requires the individual be notified of the decision within 30 days of the covered entity’s receipt of the request. See 45 C.F.R. § 164.524(b)(2)(i). You can then use this to verify if you should have more than a zero credit balance.

How can that be? I terminated the treatment 13 months in (out of 24) and the total cost was supposed to get $4,726 per their contract with Delta Dental yet they received a total of $5,070.50 between all my insurance payments and what they received from me personally.

2. Under contract law it would appear that you would owe them atleast their out of pocket costs till you termiated treatment plus the profit that they would have made on the contract if you have completed all 24 payments. This is called the benefit of the bargain damages. Other you may need to read the contract to see what it states their remedy or rights are if you terminate early.

Am I just out of luck or can I file a complaint with the American Dental Association and/or Better Business Bureau or other agency & trade group?

3. You can file a complaint with any or all of these; but first get the records and the contract you signed and see what the correct calculation entitles you to. The make a demand on the office in writing explaining your position. If they still fail to comply, then go this route.

Also, would it be best to go directly to an attorney and have a letter sent?

4. This may cost you more money than what you are out. So first do the above and see where you stand. Then you may want to pay a local lawyer $250.00 to write a demand letter.

Expert:  Maverick replied 1 year ago.

Welcome to Just Answer (“JA”)! My name is Maverick. Please note that:

(A) The information we provide is general information. No attorney-client relationship or privilege is formed by communicating with me. If you want legal advice, you must consult with a local attorney in person before acting or deciding not to act based on any information given here;

(B) When I feel that I have provided you with a complete answer, I will ask for you to assign a feedback rating so that JA will compensate me for my time; and

(C) You should not be concerned about any short delays between your questions and my replies. Please know that I answer most questions within the hour if I am signed on. If I am not signed on, then I still make every attempt to respond within 24 hours.

Thank you for taking the time to understand how this site works. By continuing, you confirm that you understand and agree to these terms.

Answer will follow in the pane below as per above parameters….

I have contacted the office multiple times now to get the financials and all i've been told is that I don't owe them any money but that I have $0 credit.

1. Send them a letter via certified mail so you have proof of delivery. You have a right under HIPAA to access all of your medical and billing records to make sure that they calculated your balance due correctly. An individual’s right of access generally applies to the information that exists within a covered entity’s designated record set(s), including: (1) a health care provider’s medical and billing records, (2) a health plan’s enrollment, payment, claims adjudication, and case or medical management record systems, and (3) any information used, in whole or in part, by or for the covered entity to make decisions about individuals. A record is any item, collection, or grouping of information that includes PHI and is maintained, collected, used, or disseminated by or for the covered entity. See 45 C.F.R. § 164.501 (definition of “designated record set”). The Privacy Rule requires covered entities to respond to requests for access in a timely manner. Except as otherwise specified, the Privacy Rule requires the individual be notified of the decision within 30 days of the covered entity’s receipt of the request. See 45 C.F.R. § 164.524(b)(2)(i). You can then use this to verify if you should have more than a zero credit balance.

How can that be? I terminated the treatment 13 months in (out of 24) and the total cost was supposed to get $4,726 per their contract with Delta Dental yet they received a total of $5,070.50 between all my insurance payments and what they received from me personally.

2. Under contract law it would appear that you would owe them atleast their out of pocket costs till you termiated treatment plus the profit that they would have made on the contract if you have completed all 24 payments. This is called the benefit of the bargain damages. Other you may need to read the contract to see what it states their remedy or rights are if you terminate early.

Am I just out of luck or can I file a complaint with the American Dental Association and/or Better Business Bureau or other agency & trade group?

3. You can file a complaint with any or all of these; but first get the records and the contract you signed and see what the correct calculation entitles you to. The make a demand on the office in writing explaining your position. If they still fail to comply, then go this route.

Also, would it be best to go directly to an attorney and have a letter sent?

4. This may cost you more money than what you are out. So first do the above and see where you stand. Then you may want to pay a local lawyer $250.00 to write a demand letter.

Expert:  Maverick replied 1 year ago.

Please see my answer above...

Expert:  Maverick replied 1 year ago.

Please see above....