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So I have this weird situation where I went to the dentist for a root canal and they filed a claim for my insurance. Now, on the EOB they've charged an excessive amount of money ($1500 for xrays) and billed prices much higher than the quoted prices. So I called them up to ask what the deal was with the charges. They told me to ignore that and that I did not owe them anything.

My theory on what's going in here is they charged more to get more money from the insurance company. They basically maxed out my insurance. I'm fine with that as long as I don't have to pay anything.

So my question is: Is it safe to believe the provider's claim that I don't owe anything? Or should I get something in writing to prevent then from sending a debt collection agency after me X years in the future?

  • Does the EOB say how much the insurance company thinks you owe? Or just how much they paid the provider? – user42405 Sep 27 '17 at 16:09
  • The EOB says the Insurance company things I owe $4500. But the provider says that I do not owe them anything – user2877750 Sep 27 '17 at 16:13
  • Is the provider "in network" (or some similar term) with the insurance plan? It'd be very surprising if they were and they disagreed on the amount you owe. If it's "out of network", it may just be that the EOB is saying that the provider has the right to balance-bill you. – user42405 Sep 27 '17 at 16:16
  • Yeah, so I asked the insurance company, the provider is apparently out of network. Even though they said I was in network... – user2877750 Sep 27 '17 at 16:19
  • Companies are very confused about what in-network and out-of-network means and often really have no idea. I've seen a doctor's office where the office was in-network but a doctor there was out-of-network, or the lab at the doctor's office is out-of-network even though the doctor's office and affiliated hospital are both in-network. It seems to me that there's a ton of paperwork for each place (even in the same building) to actually be in network that doesn't always get filled out, though with enough complaining it gets sorted out eventually. – user42405 Sep 27 '17 at 17:42
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In general, "billed amounts" don't mean a whole lot, since if the provider has a contract with the insurance company (usually called "in-network"), the insurance company picks what the rates are that the treatment "should" cost, and how that cost gets allocated between what the insurance company pays and what the patient pays. Due to that contract, the insurance company and provider should agree on how much the patient owes, and one shouldn't pay a provider more than what the insurance company says you should.

On the other hand, some insurance plans have a level of "out of network" coverage. In that case, the insurance company has its same sense of what the treatment "should" cost, but is really only concerned with paying its share. The EOB then should show how much they pay, but will generally show the full "billed amount" minus their payment as the amount the patient owes. That is, since there's no contract between the provider and the insurance company, the insurance company has no way to stop the provider from "balance billing" you for whatever they want beyond the amount that the insurance is paying, since any payment amount is purely a transaction between you and the provider.

In general (as with anything involving large amounts of money), it's best to get all you can in writing. The provider should be able to provide you with a statement showing zero remaining due, and including both any payment you've made to them and any payments made by the insurance company. It may take a while for the payment from the insurance company to be processed, and until it does there may be something on the statement showing "estimated amount to be paid by insurance", which isn't as comforting as one showing "actual amount paid by insurance" and "zero due".

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    Great advice, particularly last paragraph. – Grade 'Eh' Bacon Sep 27 '17 at 17:54
  • Definitely get the zero balance invoice. You don't want some overzealous future accounts payable person to run a muck because the last invoice indicates an amount due. – quid Sep 27 '17 at 20:32

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