fraud or just not nice?

[lyric1863]

What is the name of your state?What is the name of your state? Georgia

My ex-husband covers our children on his dental insurance. The way that it has been working is this: The children have a dentist appointment, I pay the bill in full at the time of treatment. The dentist files with his insurance. His insurance pays my ex-husband for the treatment and my ex keeps the money. He makes a profit off of the dental appointment and I pay the entire bill.

I am so tired of dealing with him and attorneys (sorry to all of you attorneys out there), but thought perhaps if this was insurance fraud that I would decide to go ahead and pursue once again.

 

[BelizeBreeze]

This is not insurance fraud. It's poor management on your part.

What the hell are you doing paying in advance for the treatment if your husband carries the insurance?

 

[lyric1863]

fraud or just not nice

I pay for it because I live in New York and he lives in Georgia. The insurance is actually from South Carolina and none of the dentists in NY are on the South Carolina network. And dentists don't work for free! So someone has to pay for it. Who would you suggest pay for it, since the mismanagment is mine?

 

[somarco]

For starters, are you children eligible dependents under your ex's dental plan? Many employer sponsored plans are redefining and auditing plans to make sure coverage is not being provided on ineligible dependents. Here in GA, Delta completed an audit and gave thousands of "illegal" dependents the boot. Some plans are defining an eligible dependent as one for whom you have legal custody AND lives in your household.

If this is an employer plan, it may be that your children are not eligible for dental (and any other coverage) under your ex's plan.

Beyond that, why are you paying the dentist in full and then letting the dentist file the claim? If you continue doing it this way you should pay the copay or deductible and let the dentist file for the balance.

Sounds like you need to reconsider the way you handle this (and maybe other) claims.

 

[lyric1863]

fraud or just not nice

Yes he is required to pay for their dental insurance. That is in the divorce agreement. As I mentioned before I do not live in the same state as my ex-husband. We are no longer on the network. I guess I should not file it with insurance, I always have some unfounded hope that my ex-husband will do the right thing. I was just hoping that him collecting and spending money for something that he did not pay for would be more than just not nice. But I pay my bills when they are due, I pay for services performed, I take care of my children....that is why I pay the dentist. Because dentists like to be paid for what they do. And I like for my children to be cavity free.

 

[somarco]

he is required to pay for their dental insurance

That is not what I addressed.

Divorce decree or not, are the children considered ELIGIBLE DEPENDENTS under his dental plan? I dont understand why this concept is so difficult to grasp.

Beyond that, if you want to continue paying the dentist, and then allowing your husband to gain by receiving "free" money, that is your choice.

 

[lyric1863]

fraud or just not nice

you actually did ask why I was paying the dentist. I replied why. Because you are supposed to pay for services is why I pay. I had him file the claim because I had hoped my ex could do the right thing without an attorney. When you are out of network, they do not accept co-pay or deductible, I do not understand why THAT concept is so difficult to grasp.

As far as what Delta does, I have no idea. He does not work for Delta. The divorce agreement states that he provide insurance. I guess if they are not eligible under his employer plan, then he would have to get private insurance. That would certainly be his problem, not mine.

Our divorce agreement does state that medical and dental costs after insurance are shared, so I do have recourse within the family courts, but it is costly and exhausting. And he evenutally comes around when forced by a judge to do the right thing.

Thanks for the replies...

 

[ablessin]

if you are paying the bill, in full - - then the dentist really need not file the claim with the carrier......... you could be considered self pay.

But - then why pay the premium (your ex, that is) - - - he is - in a sense getting paid by the carrier for your taking the kids for care....... in his eyes, he is recouping the cost of the premium (in a roundabout way)

If I was you, I would take him to court for 1/2 the bills you've paid - - you are letting him get away with this!!!
I also would get a listing of providers, and you know, even though HE is court ordered to carry the kids, if you're taking them and paying the bills anyways you might consider getting a local plan in NY that you'll have access to in-network providers........ it might be cheaper for you in the long run!
Excellus offers dental, you can buy it and it's not that expensive.
(I live in NY too)

Good luck

 

[lyric1863]

fraud or just not nice

Yes it is back to court we go....

I had tried to have new york insurance, but then the problem came into that he was still carrying the boys on his policy and since the divorce decree states that is his reponsibility,my insurance company sees his insurance to be primary. My ex would not provide me with the explanation of benefits from his insurance company to file with GHI or fill out the paperwork that GHI dental sent him. So I am paying premiums also and not able to cash in on the benefit because the ex will not cooperate until a judge tells him to cooperate. I think he likes giving money to his attorney instead of paying for his children's dental bills.

 

[ablessin]

That sucks, then.

Good luck in court - -hopefully a judge will straighten him out.

Seems stupid to me that if he's in another state and you can't get in network coverage a judge would put you through this...... maybe they don't realize that this is not working for you.

It certainly would not hurt to let the judge know this - -and if you can, provide proof that you have paid the dentist - -either copies of the cancelled checks, something.
If you can't get that - - you might be able to get a detailed account ledger from the dentist office - they might charge you - but the cost of the ledger would probably be worth it to take to court for several reasons :
1. You can show you have paid for service upfront
2. Daddy-O has not paid
3> He has not paid you back anything towards it.
4. He is not holding up his commitment

So, you might as well have the court order to carry the kids, because at least you'd have control over the situation more.

Good luck

 

[ellencee]

Ah, another case of when emotions rule...

If the dentist files on the father's insurance and insurance sends the payment to the father it seems only logical that the dentist's billing is being paid by the father's insurance which makes the "not in the network" claim a bunch of baloney.

Mom should pay the co-pay or the deductible and have the dentist file the insurance claim at the time of service, just like the dentist already does, except have the payment sent to the dentist.

I know it removes the control issue of Mom's trying to wish Dad into doing the right thing and it removes Dad's ability to keep the money...but, it solves the problem of Mom's paying the full amount to the dentist...and, it meets the intent of the court order.

EC

 

[ablessin]

They might not be able to do that - if the dentist in not participating with the insurance, they insurance won't send the payment to the dentist...... I know this because we hear it - there are a few carriers my office doesn't "par" with and they ALWAYS send the payment to the patient, and the patient is supposed to be turning into our office. (Not that they always do)

Which is what daddy should be doing.......... the insurance is giving him money for services, daddy is supposed to be forwrding the money to the provider............ IF that was happening - the dentist account would be in an overpayment status (which is illegal, by the way) and Mommy would be getting refunded.

I was just thinking for the sake of ease and to avoid this from continuing to happen, mom carry the insurance on the kids...... I wonder if this is a dental issue only, OR if it's also a medical provider issue? I can see the dentist because in NY a lot of dentists require payment up front - - for non covered expenses....... like I personally need my wisdom teeth pulled out, and my insurance will pay 50% so before I can have the work done, I have to pay my portion of the bill.
I guess dentists are sick of getting screwed.

 

[ellencee]

I went through this--insurance in Georgia, orthodontist and medical MD in NC.
If the insurance accepts billing from the provider, they can send payment to the provider. It's a matter of getting the insurance company's left hand to acknowledge what the right hand is doing--receiving billing has not let claim payment know that payment can be sent to the provider.
Mom can take it up with the insurance company. I had to send a copy of the support order to the insurance company and voila--payment went to the orthodontist or to the medical physician without ever going through Dad's hands (which led only to his pocket).

Oh--and it 's not insurance fraud for Dad to accept the insurance's benefit check. It's contempt of court for Dad not to pay for the dental expenses if the court has so ordered Dad.

EC