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I had an appointment with my dentist and they gave me a receipt with a total amount $409.00 for the services.

Then they claimed $985.00 from my insurance. Insurance paid $750.00.

They didn't ask me to pay the difference ($985.00 - $750.00) yet - and maybe they will not. Looks like this is a way to pull money from my insurance.

Should I escalate this? If yes - then how?

How can I prevent such cases in the future? - Usually, I sign an electronic document so they can change it easily

  • 2
    You said that the dentist gave you a receipt. Did you pay $409? – Ben Miller Dec 14 '17 at 2:37
  • I did not. In the receipt, it is stated that everything is covered by insurance. And I'm paying $0 – Andreo Dec 14 '17 at 4:35
  • In what sense was it forged? Did they represent this bill as being signed by you? – Acccumulation Dec 14 '17 at 15:43
  • Is this affecting your "total covered amount" by the dental insurance plan? Is that why you are wishing the $750 payment was only $409 instead? – TTT Dec 14 '17 at 21:13
  • Is this affecting your "total covered amount" - Yes. They did really bad treatment and I had to fix it with another doctor - that's why I started to investigate why they claimed a higher amount from insurance – Andreo Dec 18 '17 at 2:41
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With every medical bill covered under insurance there are multiple prices involved. Some depend on if the item is 100% covered, partially covered, covered with a co-pay, out-of-network, or not covered.

In general here a 4 numbers:

  • Full price (the amount somebody would pay without insurance)
  • The negotiated price. This is the amount that the insurance company and the doctor has agreed the procure is worth.
  • What the policy will pay. This number is flexible depending on the exact policy and whether you have meet your deductible.
  • what the patient owes.

Now for some examples:

100% coverage:

  • $985 full price
  • $750 negotiated price
  • $750 what the insurance policy will pay
  • $0 what the patient pays
  • note the difference between $985 and $750 is not recaptured

Partial coverage

  • $985 full price
  • $750 negotiated price
  • $341 what the insurance policy will pay
  • $409 what the patient pays
  • note the difference between $985 and $750 is not recaptured

Covered with copay

  • $985 full price
  • $750 negotiated price
  • $720 what the insurance policy will pay
  • $30 what the patient pays
  • note the difference between $985 and $750 is not recaptured

Out of network

  • $985 full price
  • $750 negotiated price, which the doctor ignores
  • $341 what the insurance policy will pay
  • $644 what the patient pays
  • note the difference between $985 and $750 is recaptured
  • also frequently that extra amount isn't included in the out-of-network deductible or the out-of-pocket calculation.

Not covered

  • $985 full price
  • $750 negotiated price, which the doctor ignores
  • $0 what the insurance policy will pay
  • $985 what the patient pays

To understand what is being billed/covered look for an EOB - Explanation of Benefits related to your visit. This document created by the insurance company explains all the charges related to that visit. The complexity is that each item in a single visit can be covered differently. Cleaning at the dentist can be 100% covered, while an optional procedure only partially covered.

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    Just so it's said...not many people, even uninsured, pay the "full price". Many providers discount services for people who don't have insurance -- partly because the "full price" is marked up anyway in an attempt to get the insurance company to come up off the "negotiated price" they really want. – cHao Dec 14 '17 at 20:42
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The insurance company is probably not getting ripped off.

When you go to the dentist or doctor, most people do not shop around for price. Therefore, you have no way of knowing what the going market rate is for a particular procedure, and you don't know if you are getting a good deal or not.

Insurance companies, however, know exactly what they should be paying for every procedure, because they deal with lots of providers. That is why they are paying less than the provider billed. Generally, the provider will put whatever they want on the invoice, but the insurance company will only pay up to the current market "fair" price, which they call the negotiated rate.

As long as the invoice that the provider sent accurately names the procedure that you had done, rest assured that the insurance company is paying no more than they want to pay for that procedure.

As to why you got a statement with a smaller amount, it is not uncommon for providers to give a cash discount for people paying without insurance. It saves the provider from insurance paperwork, gets them their payment quicker, and gives a break to patients that don't have insurance.

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