My dentist sent a forged bill to my insurance (California, US)
I had an appointment with my dentist and they gave me a receipt with a total amount 9.00 for the services.
Then they claimed 5.00 from my insurance. Insurance paid 0.00.
They didn't ask me to pay the difference (5.00 - 0.00) 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
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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:
5 full price
0 negotiated price
0 what the insurance policy will pay
[CO] what the patient pays
note the difference between 5 and 0 is not recaptured
Partial coverage
5 full price
0 negotiated price
1 what the insurance policy will pay
9 what the patient pays
note the difference between 5 and 0 is not recaptured
Covered with copay
5 full price
0 negotiated price
0 what the insurance policy will pay
what the patient pays
note the difference between 5 and 0 is not recaptured
Out of network
5 full price
0 negotiated price, which the doctor ignores
1 what the insurance policy will pay
4 what the patient pays
note the difference between 5 and 0 is recaptured
also frequently that extra amount isn't included in the out-of-network deductible or the out-of-pocket calculation.
Not covered
5 full price
0 negotiated price, which the doctor ignores
[CO] what the insurance policy will pay
5 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.
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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