Dentist charged in excess of HMO negotiated fees

[mittner1]

What is the name of your state?Ohio
When I go to my HMO plan's approved dentist, I am supposed to get reduced fees. I was charged $1199 over the HMO's fee schedule for my son's oral surgery. I questioned the fees at the time, because the amount that I was being charged was higher than what I was originally quoted. They said they had recently been in contact with my HMO and this was the fee that had been determined. I paid them by credit card.

I filed a complaint with my HMO. Their response was simply to send me an explanation of benefits showing that I was overcharged. I called and sent a certified letter to the dentist, requesting written clarification or a refund, but they have not responded. I checked the Better Business Bureau report on this dental group, and they have a an unsatisfactory record primarily due to billing issues.

I have looked into contesting the charges with my credit card company, but they said that this is not the type of thing that can be contested.

There is a complaint process with my HMO, and currently I am in the second step of that process.

Doesn't my HMO have an obligation to see that the approved providers charge according to their schedule? Shouldn't my HMO be able to collect since they agree I was overcharged? Doesn't my HMO have a contract obligating the dentist to charge according to the negotiated fees?

What options do I have?

Thank You.

 

[JETX]

Doesn't my HMO have an obligation to see that the approved providers charge according to their schedule?

Possibly. Contact the HMO and tell them that one of their member practitioners is in apparent violation of the HMO agreement.

Shouldn't my HMO be able to collect since they agree I was overcharged?

Nope. He is YOUR dentist and you are the one who paid.

Doesn't my HMO have a contract obligating the dentist to charge according to the negotiated fees?

There would normally be a 'fee agreement' between the HMO and the practioner.

What options do I have?

You could consider filing a small claims action against the dentist.

 

[MellowCat]

There is a complaint process with my HMO, and currently I am in the second step of that process.

Doesn't my HMO have an obligation to see that the approved providers charge according to their schedule?

Yes. And HMO's frown on providers billing over their fee schedule.

Shouldn't my HMO be able to collect since they agree I was overcharged?

No, but they normally will contact the provider to question the bill on your behalf, especially if they feel you are being unfairly billed.

Doesn't my HMO have a contract obligating the dentist to charge according to the negotiated fees? Yes. But are you absolutely certain they overbilled you? Did the HMO specifically admit that you were overbilled? Because it sounds to me like you owe the fee but your carrier isn't wanting to "look like the bad guy." It shouldn't require any appeals for the carrier to look at the claim they processed and see what your co-insurance obligation is. The dentist probably assumes you should have a copy of the EOB that shows the amount you owe and that they have no further obligation to explain any more than that. Also, fee schedule amounts are confidential, so it is unclear how you obtained the fee schedule information to begin with.

What options do I have?

Look at your EOB and see what it says you owe the provider. If it says you owe less than you actually paid, then contact the dentist over and over and demand their attention. Also, I would continue the complaint process through the carrier because I've never heard of an HMO that "isn't interested" in a provider overcharging their policyholders. As I said before, if they are making you appeal and and furnish them copy of the EOB that they should already have (since they are the ones who generated it, geez), then something tells me that you owe the bill.

 

[mittner1]

"As I said before, if they are making you appeal and and furnish them copy of the EOB that they should already have (since they are the ones who generated it, geez), then something tells me that you owe the bill."

Yes, the insurer has provided me with the explanation of benefits. It clearly shows I was overcharged and when I spoke with them they said that I was overcharged. They have contacted the dentist and also given the dentist all of the information.

The insurer says they have contacted the dentist and are waiting for a response. Twe weeks later neither I nor the insurer has gotten a response. The dentist simply doesn't respond to communications.

"fee schedule amounts are confidential, so it is unclear how you obtained the fee schedule information to begin with."

I received the fee schedule as a response after I filed the first step of the complaint process with my insurer.

 

[MellowCat]

Well at least the carrier is investigating this. I would give it a couple more weeks to hear from the dentist. If they don't do the right thing (or don't respond), I would file a complaint on this dentist with the state dental licensing board. Obviously you will need to keep records of all correspondence to support your case. If the dentist has unlawfully been billing patients, I'm sure the Board would be interested in hearing about it.

The fee schedule thing still surprises me. Physicians are reminded over and over by carriers they contract with that their fee schedule information is *highly* confidential and "sharing it with anyone is strictly prohibited." That they furnished you with that information really blows my mind. Anyway, it's neither here nor there. Good luck.

 

[JETX]

If they don't do the right thing (or don't respond), I would file a complaint on this dentist with the state dental licensing board.

Why??? What the hell does the stae 'dental licensing board' have to do with any of this???
Why is it that people think that a state agency is the 'end all, catch all' for all issues?? Simply, the state licening board has absolutely NOTHING to do with whether a dentist abides by his PRIVATE agreement with an HOA!!!

If the dentist has unlawfully been billing patients, I'm sure the Board would be interested in hearing about it.

Again, why?? The 'board' has NO involvement in this issue. I suggest you spend a few sessions before ANY state licensing agency arguing positions.... then you will realize that most of these agencies are self-serving 'licensing boards' whose main interest is to APPEAR to be consumer-conscious and self-regulating.... so that the legislature doesn't 'interfere'. They will not hear an issue of a complaint about billing.

that information really blows my mind.

Maybe that explains it!

 

[MellowCat]

JETX,

I don't know what you're getting all riled up about. I work for surgeons and know that the Licensing Board is who has, in two instances, been the entity "to put the pressure on" when a patient was being billed incorrectly. How? The patient contacted them and they went to work on us. (It happened twice with one of our new surgeons. I think she has now learned her lesson about accurate paperwork.)

The poster didn't appear to be getting anywhere with either the doctor or the carrier, so I offered advice I believe will work for her situation. She has now stated the Ins. Co. is investigating the matter, so hopefully it won't come to that. Your experience in the "licensing board" area obviously differs from mine. I feel that is a better route than small claims court at this time.

 

[mittner1]

Well at least the carrier is investigating this. I would give it a couple more weeks to hear from the dentist. If they don't do the right thing (or don't respond), I would file a complaint on this dentist with the state dental licensing board. Obviously you will need to keep records of all correspondence to support your case. If the dentist has unlawfully been billing patients, I'm sure the Board would be interested in hearing about it.

I might try the state licensing board, state attorney general's office, or Better Business Bureau. These entities may not resolve the situation, but they would apply some pressure.

The fee schedule thing still surprises me. Physicians are reminded over and over by carriers they contract with that their fee schedule information is *highly* confidential and "sharing it with anyone is strictly prohibited." That they furnished you with that information really blows my mind. Anyway, it's neither here nor there. Good luck.

The fees they have listed are just the fees for the specific procidures relating to my son's surgery. They have listed the insurer's payment and my responsibility, in comparison to what I was billed for each procedure. There are 15 procedures listed.

I have been doing a little internet research about this medical group, and they were the subject of a local televsion news investigation 2 years ago. There were many complaints to the state attorney general's office and BBB regarding billing practices.

 

[JETX]

I don't know what you're getting all riled up about.

I get 'riled' when some yahoo comes on the forum and they do NOT understand the issues.... yet, there first (and only) answer is.... turn them into the AG's office, or licensing agency, or whoever.
These agency's will only get involved in rare cases, usually where there are numerous complaints about an individual or firm.
In this case, there is NOTHING to even suggest that the dentist has overbilled the patient.... only that the dentist MAY be in violation of his agreed fee basis with the HOA. No matter how you 'spin' it... that is NOT overcharging.

I work for surgeons and know that the Licensing Board is who has, in two instances, been the entity "to put the pressure on" when a patient was being billed incorrectly. How? The patient contacted them and they went to work on us. (It happened twice with one of our new surgeons. I think she has now learned her lesson about accurate paperwork.)

Being billed 'incorrectly' is NOT the same as this matter. See above.

The poster didn't appear to be getting anywhere with either the doctor or the carrier, so I offered advice I believe will work for her situation.

Sorry, but it will not.

She has now stated the Ins. Co. is investigating the matter, so hopefully it won't come to that.

Yep. And that is the appropriate process to try to resolve the matter..... leaving it between the HMO and the DDS.

Your experience in the "licensing board" area obviously differs from mine.

That is because I understand the legal and regulatory issues raised by the OP.

I feel that is a better route than small claims court at this time.

Your 'feelings' are noted.... but not really relevant to the FACTS.

 

[MellowCat]

JetX,

I don't believe I'm a "yahoo," but whatever. I stand by my advice regardless of your own perceived "expertise" in the matter.

 

[cbg]

C'mon guys. Is it really that big a deal?

Okay, so the poster calls the state. One of two things will happen:

1.) The board says, "Sorry, we don't get involved in this kind of issue". End of phone call. Poster gets no help, but loses nothing except a little time and the cost of the phone call.

2.) The board says, "We'll send you the paperwork to file your complaint". Poster files complaint.

Either way, is it really worth getting upset about?

 

[JETX]

Either way, is it really worth getting upset about?

Not to me!!

 

[ablessin]

She needs to make sure that the dentist she saw was/is PAR(ticipating) with her HMO plan.. because that will answer A LOT right there.
If they are PAR, then they can only bill what the HMO allows the office to bill.

If they are NONPAR, the office can balance bill the patient for whatever $ is left after her insurance payment is made.

I would start there, before calling the state board. I am not sure how far the poster will get - although is certainly IS worth a try if worse comes to worse.

Best of luck

 

[mittner1]

Yes the dentist is a participating provider with my HMO.

I know the dentist is supposed to only charge what is negotiated with the HMO. But they charged much more than that. That was the point of my post.

Update: After 2 certified letters and about 10 phone calls, I now have a letter from my HMO stating that my dentist has indeed overcharged me and has now agreed to reimburse me for $1199.

I don't have the check yet but I am feeling better about the situation. Thanks everyone for your help.

 

[MellowCat]

Yes the dentist a participating provider with my HMO.

Have you STILL not heard from your carrier or dentist regarding this?!?