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I had an orthodontic procedure done. The total bill was $10k. My insurance covers 90% of this procedure.They processed the claim and it shows coverage at about 60% of the total amount.

I called the insurance company and they said that the dentist has a set fee for this procedure. It is NOT $10k but $8k so we will cover 90% of that amount. So where did that extra $2,000 go to?

The contract says that I am responsible for what the insurance does not pay but what do I have to do with what he charged them or gets for some contract fee?

So now I am responsible for that $2k plus 10% of the covered amount of $8k? This is very misleading and feels like a scam.

How do I get the orthodontist to rebill the insurance for the full amount of $10,000 so that my bill is the expected $1k? Or if the total amount is $8k then how do I get my total bill adjusted to the correct total amount? Otherwise what's the point of having insurance cover something at a certain rate if they can add on whatever they want?

EDIT:
Maximum covered is 15k for this procedure and have never used any of this benefit

Provider is In-Network

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    When you had your initial consultation, you should have been presented with a cost for services and if you agreed to that amount, treatment would begin. How much was THAT amount? (not the billed amount or the insurance coverage amount). – Bob Baerker Oct 28 at 18:24
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    Why does the insurance company believe that this orthodontist typically charges 8K? What's their source? Once they present you with that info contact the orthodontist and ask him to clarify why he charged 2K more than normal. Have him share that information with the insurance company. – Dugan Oct 28 at 18:40
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    @Dugan - The ins company has no belief as to what the dentist charges. They have a payment schedule for services rendered. A non participating dentist (out of network) can charge whatever he likes for services. Scheduled coverage by insurance company for the ortho treatment is $8k with a 10% patient copay or $800. If $10k then the patient would be responsible for the total difference ($2,800). There's no impropriety there. There would be if an in network dentist was attempting to charge more than the $8k amount. The real problem is what did the patient agree to before treatment was begun? – Bob Baerker Oct 28 at 18:58
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    Usually dental insurance has an annual maximum, which is the maximum the insurer will pay in a year. This is different than an annual maximum under medical insurance which is typically the maximum out of pocket for the member. What bob is saying is completely accurate, in-network providers, are generally barred from balance billing under their network contract. SOME will still TRY. BUT, you may have exhausted your dental insurance maximum, which puts you on the hook for the balance. It's not really clear where the details fall in your question. – quid Oct 28 at 20:35
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    @Greg McNulty - I typoed up above and wrote (905 of $8k) when I meant 90%. I doubt that was critical to understanding my comment but just in case, I'm mentioning it. The initial reason that I refrained from an answer wass because as quid suggested, it wasn't clear where the details fall in your question. The back and forth in the comments have fleshed out some of them so an answer at this point would be superfluous. – Bob Baerker Oct 28 at 21:34
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(Answer was edited based on OP's edits and comments, see the bellow for the original answer)

You said that the orthodontist billed insurance $8k, so insurance paid based off of $8k (all is good).Then you got the bill from the orthodontist and they said the total amount is $10k (uh oh).

In other words the orthodontist charged you more than what they charged insurance. You should contact the orthodontist and have them explain why they have two amounts for the same procedure. You can even tell them "I called my insurance and they said you have a set fee of $8,000 for this procedure and that is what you billed them for. I will only pay my coinsurance based on that amount".


By the way,

The contract says that I am responsible for what the insurance does not pay

is 100% normal and does not mean the orthodontist is trying to screw you. This simply protects them from the people that don't understand coinsurance/copays and say "I have insurance so I shouldn't have to pay anything!". But, if the orthodontist is in-network and they charge you more than the contract amount, that's a problem!

In your case you can demand that you will only pay based on $8,000 since that's what they told your insurance the procedure cost.


ORIGINAL ANSWER

The insurance company has a "book" of covered procedures and the acceptable fee for those services. If a medical provider is in the insurance company's network, then they agree to accept the amount given in the "book" as payment in full for the service. This is called the "negotiated", "contract", or "covered" amount.

If they are out of network

The insurance "book" says that your procedure should cost $8,000. But, your orthodontist is not in their network so he doesn't have to abide by that rate. So he bills insurance $10,000 and they say "we will only cover 90% of $8,000". This means you pay 10% copay on $8,000 and then the full amount above $8,000. Or 0.1*8000 + (10,000 - 8,000) = $2,800

If they are in network

The orthodontist can still bill as much as they want ($10,000) but then insurance will come back and say "you are in network and the contract amount for this procedure is $8,000". The orthodontist should then send you a bill like this:

Procedure cost: $10,000
Insurance negotiated amount: $8,000
Insurance payed: $7,200
YOU OWE: $800

TL;DR

The orthodontist can bill insurance whatever he wants, but if he is in-network then he must abide by their "negotiated" rate. Contact your insurance or login to your online account and figure out if the orthodontist is in-network.

  • If he is not, then everything is as it should be (assuming the math checks out).

  • If the orthodontist is in network, you should contact your insurance and tell them an in-network provider is charging you more than the negotiated amount.

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    If the provider is out of network, you can (and should) press them hard on the $8k vs $10k difference and see if they will negotiate. The insurer stating that their rate is $8k is a pretty good sign that the industry, at large, is accepting of an $8k rate for that procedure. – dwizum Oct 28 at 19:58
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    @GregMcNulty I have changed my answer based on your edits and comments. Let me know if I misunderstood what you said. – Nosjack Oct 28 at 20:57
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    @nosjack: thanks for the updates. I contacted insurance, they said my only responsibility is 10% the contracted rate for this service. I called the ortho office and now they are saying there are extra "record" fees, blah blah blah...that response right there confirmed to me they are charging me more...uggg. – Greg McNulty Oct 31 at 20:51
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    @GregMcNulty I would expect "record fees" to be a separate line item on the claim AND on the bill you received from them. They are essentially not billing insurance for something and making you pay it directly. Ask them to either submit a new claim with correct line items, or an additional one for the "record fees". (Also, $2k for "record fees" is ridiculous. If I were you I wouldn't go back to this orthodontist again...) – Nosjack Oct 31 at 20:56
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    @Nosjack And I would let the insurance know what happened. They're not going to like that! – Loren Pechtel Nov 1 at 7:19
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Typically, insurances agree with the doctors on a defined amount for a procedure - and the doctor accepts that, that is what in-network means.

if the doctor bills a higher amount than that agreed amount to the insurance, they will just discard the remainder, and ignore it - after all, the doctor agreed to not charge more, period.

if you agreed with the doctor that he charges the higher price, it is now your responsibility to pay the difference (yeah, ugly).
The question would be - did you agree?

You should have gotten a detailed cost and execution plan, in written, from the doctor, before the activity started. If this showed the higher price, and you signed it, then you accepted it (and you have to pay the remainder). If that plan does not show the higher price, or you never signed a plan, the doctor would have difficulties to force that money from you.

Either way, most doctors are willing to negotiate with you, and if he got 6000+ from the insurance, he is probably willing to waive the remainder.
Call them, and explain nicely that you didn't understand that, and have huge difficulties to pay the remainder, and ask if there's any way they could waive it. Important: be nice and ask for their help, don't request.

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    This isn't accurate. It doesn't matter if the patient agrees, the provider's network agreement prohibits balance billing, period. This issue here that's still unaddressed by the question is the annual maximum on the dental plan, because this additional $2k might not actually be a balance bill. This might simply be the remainder of the covered amount in excess of the annual maximum, which is relatively common in dental programs. – quid Oct 29 at 0:36
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    I would assume that depends on the contract and the network, and is not a general limitation. At least I see it all the time, and when I tell my doctor 'you can't bill me the balance', he says 'watch me!'. – Aganju Oct 29 at 0:43
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    You are injecting uncertainty in to a part of this system that is not uncertain. You definitely do not see in-network doctors routinely balance billing in-network patients. You see out of network providers do that. And physical therapy and chiropractors and other non-doctor in-network providers may try to balance bill. And this isn't a medical insurance issue, this is a dentist, dental insurance, and orthodontia benefit. – quid Oct 29 at 0:48
  • @quid: yes, way under the maximum. the ortho office is say its record keeping fees now and "special" lab fees. Umm no, that is standard part of the related services. – Greg McNulty Oct 31 at 20:53
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    @GregMcNulty Be sure to let the provider know that you intend to file a grievance with your insurance company because they did not adequately inform you of these charges and they are not customary. Point out that you specifically chose an in network provider to avoid unexpected additional charges and point out that you will point that out to your insurance provider. – David Schwartz Nov 1 at 15:09

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