Insurance asking to repay for services not provided

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Topic Author
chr
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Joined: Sun Sep 16, 2018 6:17 pm

Insurance asking to repay for services not provided

Post by chr »

Hi all,

I have a problem with my dental insurance and hope somebody will be able to help me. I try to keep this short so please let me know if you need additional details.

I went to the dentist in May about 4 months ago for a routine exam. I picked an in-network dentist which was close-by. The dentist decided I needed some fillings on both sides of the mouth and offered to do one side right away. I agreed and got my teeth cleaned and the dentist did something for about 5-10min. The rest was done by other people. When I left I was asked to pay around 450$ for 5 fillings on the left hand side. At that point I was not too clear in my mind because of the drugs they gave me and paid as requested.

When I came home I realized that there is no way that all these fillings were done and also I realized it was the right hand side the dentist worked on. I logged into my online account of my dental insurance and realized that they billed both sides to the insurance company (11 fillings). I immediately called my dentist and got very rude treatment on the phone insisting all the fillings on the left hand side were done and this is the only thing they billed the insurance for. Therefore, I lost trust in the dentist and I called my insurance informing them that the dentist only touched the right side and requesting them to not pay the dentist for all these fillings. They told me they cannot stop the mailing of the check and that they will have to ask the dentist for a refund.

Fast forward at this point I have confirmation by a new dentist that none of the fillings were done and the insurance company is asking me to pay them back the money that they paid the dentist for all of the fillings. This has become an urgent problem as they wanted the money by the first of September (despite the letter being dated 12th September) and they are threatening to send it to collections. The few calls I had earlier with the insurance were pointless because the representatives don't seem to understand the situation well.

My question to you is have you heard of something like this happening before? Can the insurance ask me to repay them despite the fact that they paid the dentist and I had no way to approve this payment and even tried to stop it from happening? I am planning to call my insurance tomorrow morning and get this sorted. What should I tell the insurance company? Which department should I ask for that would be able to deal with this?

I would be very grateful if you could help me out with any kind of tips or information.
chessknt
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Re: Insurance asking to repay for services not provided

Post by chessknt »

State insurance commissioner referral for fraud if the first dentist won't refund your insurance company and you for work not done. Make sure you are understanding the charges correctly. Insurance company is posturing I wouldn't worry about any kind of arbitrary deadline they set.
Topic Author
chr
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Re: Insurance asking to repay for services not provided

Post by chr »

Thanks for the answer. Actually I did not mention this before, but the dentist actually refunded me the $450 (after many phone calls). They are just not refunding the insurance company.

I am really worried that the insurance company is destroying my credit if I do not pay them. What I do not understand is if they legally have the right to ask me to repay them money which they paid to the dentist. To me this is absurd, if this was the case it would be really easy for dentists to make some extra money by filing some false claims and then just not refund the insurance company once they figure it out.
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BolderBoy
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Re: Insurance asking to repay for services not provided

Post by BolderBoy »

chr wrote: Sun Sep 16, 2018 7:31 pm Thanks for the answer. Actually I did not mention this before, but the dentist actually refunded me the $450 (after many phone calls). They are just not refunding the insurance company.
You need to speak to the fraud department of the insurance company. The fraudulent claim submitted by your former dentist was submitted, "on your behalf". You want to make sure that the insurance folks realize that you were not complicit in that fraud.

IANAL.
"Never underestimate one's capacity to overestimate one's abilities" - The Dunning-Kruger Effect
livesoft
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Re: Insurance asking to repay for services not provided

Post by livesoft »

So the dentist paid you instead of the insurance company? I don't get why you don't pay the insurance company the ill-gotten $450 that you got.
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Topic Author
chr
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Re: Insurance asking to repay for services not provided

Post by chr »

I am sorry I might not have been very clear. The dentist charged me $450 for the services that they did not provide and the insurance about $630. The dentist has repaid to me the $450 that I paid them, but has not paid the $630 to the insurance company. The dentist keeps telling me they will pay the insurance company back but it seems they have not. The insurance company now wants to get from me the $630 they paid to the dentist. I just moved to the US 2 years ago so I do not really know the system. To me it seems strange that I would be liable to pay this money to the insurance company.
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cheese_breath
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Re: Insurance asking to repay for services not provided

Post by cheese_breath »

chr wrote: Sun Sep 16, 2018 8:46 pm I am sorry I might not have been very clear. The dentist charged me $450 for the services that they did not provide and the insurance about $630. The dentist has repaid to me the $450 that I paid them, but has not paid the $630 to the insurance company. The dentist keeps telling me they will pay the insurance company back but it seems they have not. The insurance company now wants to get from me the $630 they paid to the dentist. I just moved to the US 2 years ago so I do not really know the system. To me it seems strange that I would be liable to pay this money to the insurance company.
The insurance company may be taking the stance they're not responsible if you chose a crook for a dentist, so they shouldn't get stuck with the loss. Is this insurance through your employer, or did you purchase it yourself? If through your employer, report it to your HR department and they might put pressure on the insurer. Also, as recommended above talk to fraud department at the insurance company.
The surest way to know the future is when it becomes the past.
toofache32
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Re: Insurance asking to repay for services not provided

Post by toofache32 »

I am both a dentist and physician. I am generally, by default, a defender of healthcare providers since we are so often under attack by people who have unreasonable expectations, have no understanding of the unpredictable nature of biology, and no understanding of how clinical decision making works. But this sounds like you have actually done appropriate investigations and I believe you are correct if you say another dentist has confirmed the work was only done on one side.
There are multiple explanations to this:

1. First the obvious: your dentist is a crook. This is actually the least plausible explanation because no dentist is stupid enough to think they can get away with this.
2. Your dentist is not a crook, but they work for a DSO where the dentist is just an employee and has no ownership, and the corporation does the business side. While these corporate entities are notorious for the scams they pull, this is still beyond what I would expect even from those fraudsters.
3. This is actually most probable: a treatment plan was created prior to treatment which included fillings on both sides of the mouth. Only part of the treatment plan was performed that day on one side of the mouth. The girl in the back room with the high school education who submits bills to the insurance company referred to the treatment plan of fillings on both sides instead of noting that only part of the treatment plan was completed. She therefore billed out the entire treatment plan instead of the partial treatment plan.
toofache32
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Re: Insurance asking to repay for services not provided

Post by toofache32 »

cheese_breath wrote: Sun Sep 16, 2018 9:28 pm
chr wrote: Sun Sep 16, 2018 8:46 pm I am sorry I might not have been very clear. The dentist charged me $450 for the services that they did not provide and the insurance about $630. The dentist has repaid to me the $450 that I paid them, but has not paid the $630 to the insurance company. The dentist keeps telling me they will pay the insurance company back but it seems they have not. The insurance company now wants to get from me the $630 they paid to the dentist. I just moved to the US 2 years ago so I do not really know the system. To me it seems strange that I would be liable to pay this money to the insurance company.
The insurance company may be taking the stance they're not responsible if you chose a crook for a dentist, so they shouldn't get stuck with the loss. Is this insurance through your employer, or did you purchase it yourself? If through your employer, report it to your HR department and they might put pressure on the insurer. Also, as recommended above talk to fraud department at the insurance company.
Dental insurance plans have clauses that state if they are unable to recoup losses from one entity, they are entitled to recoup it from another. The most common example is that when a patient receives treatment at a dental office and the insurance pays for the treatment. Then a year letter an audit reveals the insurance should not have paid for the treatment. So they ask the dentist to refund the money. When they don't refund, the insurance company deducts the payment from future patients. This is the same thing with a refund from the patient instead of the dentist. Criminal, if you ask me. They always win.
Topic Author
chr
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Re: Insurance asking to repay for services not provided

Post by chr »

@toofache32. Thanks for your explanations. According to my experience with that dentist's office manager I believe you are correct and the 3rd option is probably what happened. I only managed to get movement into that case and get my $450 back after my new dentist called my old dentist. But what I do not understand is why is the insurance not just offsetting the amount with some future claim of some other patient instead of trying to get the money from me? It seems to me that it would be very easy for the insurance company to get the money from the dentist.

@cheese_breath. Thanks. The insurance was indeed through my former employer. I will call HR and see if they are able to help me. With regards to the crook dentist. I was in the assumption that given the dentist is in the insurance company's network they would have made sure it is not a crook. Am I wrong about this and they actually just take everybody in their network?
toofache32
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Re: Insurance asking to repay for services not provided

Post by toofache32 »

chr wrote: Sun Sep 16, 2018 9:44 pm With regards to the crook dentist. I was in the assumption that given the dentist is in the insurance company's network they would have made sure it is not a crook. Am I wrong about this and they actually just take everybody in their network?
How would they "verify" this? The form I filled out for dental insurance plans was only 2 pages. They ask very basic questions. Have I been disciplined by my state dental board? Have I been sued? They want a copy of my dental school diploma and state dental license. Yes, they take virtually all dentists.
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ResearchMed
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Re: Insurance asking to repay for services not provided

Post by ResearchMed »

toofache32 wrote: Sun Sep 16, 2018 10:05 pm
chr wrote: Sun Sep 16, 2018 9:44 pm With regards to the crook dentist. I was in the assumption that given the dentist is in the insurance company's network they would have made sure it is not a crook. Am I wrong about this and they actually just take everybody in their network?
How would they "verify" this? The form I filled out for dental insurance plans was only 2 pages. They ask very basic questions. Have I been disciplined by my state dental board? Have I been sued? They want a copy of my dental school diploma and state dental license. Yes, they take virtually all dentists.
chr:

Basically, the insurer (and others) would have no way to know any provider was a "crook" (IF that's what it ends up being, this time or others) until/unless there were several complaints that were not resolved properly. And even then, they system isn't really set up to handle this well, so it might take a while.
But it would REQUIRE that there be complaints, so that's another reason to contact the insurance company's fraud department.
IF it's "just error or sloppiness", that would get resolved. But IF it turned out to be something worse, then they might start investigating, especially if there were other similar episodes still unresolved.

So do notify them, for your own benefit, but also to "encourage" the system to operate honestly, etc.

Sorry that you had to encounter this, and for now, yes, it's most likely to be some sort of error that no one is following up on... yet. Let's hope that's all it is.

And glad you've found a better dentist (with better office staff!).

And... Welcome to Bogleheads!

RM
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Topic Author
chr
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Re: Insurance asking to repay for services not provided

Post by chr »

Thanks you all for your help. I wanted to give an update and ask for some more advice.

I called my insurance company today and they told me that they actually will not try to collect the money from me but from the dentist. Of course I was happy about that but the person on the phone was only willing to confirm this verbally but not in writing. I read the letter that they sent me again and it clearly says in the letter that my dentist did not respond to them and that they are now asking me to pay. So I am a bit confused now. The letter from the insurance is not consistent with what I was told on the phone by their representative. I am still worried that they are going to send it to some collection agency and destroy my credit. Especially because the representative also told me that this is going to be the last letter they send before they send it to collections. Can anyone tell me how high they think this risk is that they will try to collect it from me and destroy my credit? Has this happened to anyone or does anyone know of such a case?
Thesaints
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Re: Insurance asking to repay for services not provided

Post by Thesaints »

chr wrote: Mon Sep 17, 2018 9:35 pm Thanks you all for your help. I wanted to give an update and ask for some more advice.

I called my insurance company today and they told me that they actually will not try to collect the money from me but from the dentist. Of course I was happy about that but the person on the phone was only willing to confirm this verbally but not in writing. I read the letter that they sent me again and it clearly says in the letter that my dentist did not respond to them and that they are now asking me to pay. So I am a bit confused now. The letter from the insurance is not consistent with what I was told on the phone by their representative. I am still worried that they are going to send it to some collection agency and destroy my credit. Especially because the representative also told me that this is going to be the last letter they send before they send it to collections. Can anyone tell me how high they think this risk is that they will try to collect it from me and destroy my credit? Has this happened to anyone or does anyone know of such a case?
Why are they asking you for the money at all ?
You didn’t submit any paperwork, your dentist did, You did not get any money, your dentist did.
It is an issue between them and the dentist.
toofache32
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Re: Insurance asking to repay for services not provided

Post by toofache32 »

Thesaints wrote: Mon Sep 17, 2018 10:18 pm
chr wrote: Mon Sep 17, 2018 9:35 pm Thanks you all for your help. I wanted to give an update and ask for some more advice.

I called my insurance company today and they told me that they actually will not try to collect the money from me but from the dentist. Of course I was happy about that but the person on the phone was only willing to confirm this verbally but not in writing. I read the letter that they sent me again and it clearly says in the letter that my dentist did not respond to them and that they are now asking me to pay. So I am a bit confused now. The letter from the insurance is not consistent with what I was told on the phone by their representative. I am still worried that they are going to send it to some collection agency and destroy my credit. Especially because the representative also told me that this is going to be the last letter they send before they send it to collections. Can anyone tell me how high they think this risk is that they will try to collect it from me and destroy my credit? Has this happened to anyone or does anyone know of such a case?
Why are they asking you for the money at all ?
You didn’t submit any paperwork, your dentist did, You did not get any money, your dentist did.
It is an issue between them and the dentist.
You would be amazed at how the contracts give the insurance companies the right to seek recovery of funds from any party involved. The patient did not receive the money, but the patient did receive the services paid for with insurance money.
Thesaints
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Re: Insurance asking to repay for services not provided

Post by Thesaints »

Well, it seems they did not. That’s why the insurance company wants their money back, but the patient cannot be responsible for the dentist’s fraud.
mouses
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Re: Insurance asking to repay for services not provided

Post by mouses »

I am not a lawyer nor a dentist, but I would not pay the insurance company. I would write a detailed letter to the insurance company, ccing it to the dentist and the state dental board (the latter will likely not do any good, since I can tell you from experience that state medical boards do not get involved in medical doctor fraud situations but I would do that anyway out of general principles.)

Be sure to include the other dentist's report that the work was not done.

Then I would let them all pound sand. If they make an entry on your credit report, you have the right to attach an explanation.

(Is the dental insurance actually saving you any money other than this? You might want to consider if you need it.)
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ResearchMed
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Re: Insurance asking to repay for services not provided

Post by ResearchMed »

mouses wrote: Tue Sep 18, 2018 3:01 am I am not a lawyer nor a dentist, but I would not pay the insurance company. I would write a detailed letter to the insurance company, ccing it to the dentist and the state dental board (the latter will likely not do any good, since I can tell you from experience that state medical boards do not get involved in medical doctor fraud situations but I would do that anyway out of general principles.)

Be sure to include the other dentist's report that the work was not done.

Then I would let them all pound sand. If they make an entry on your credit report, you have the right to attach an explanation.

(Is the dental insurance actually saving you any money other than this? You might want to consider if you need it.)
How about a copy to the State Insurance Commissioner's Office, while you are making/sending copies!
These folks sometimes actually have some clout.

RM
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student
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Re: Insurance asking to repay for services not provided

Post by student »

chr wrote: Mon Sep 17, 2018 9:35 pm Thanks you all for your help. I wanted to give an update and ask for some more advice.

I called my insurance company today and they told me that they actually will not try to collect the money from me but from the dentist. Of course I was happy about that but the person on the phone was only willing to confirm this verbally but not in writing. I read the letter that they sent me again and it clearly says in the letter that my dentist did not respond to them and that they are now asking me to pay. So I am a bit confused now. The letter from the insurance is not consistent with what I was told on the phone by their representative. I am still worried that they are going to send it to some collection agency and destroy my credit. Especially because the representative also told me that this is going to be the last letter they send before they send it to collections. Can anyone tell me how high they think this risk is that they will try to collect it from me and destroy my credit? Has this happened to anyone or does anyone know of such a case?
Are you in a state where you are allowed to record a phone call without the other side's permission? If so, call back and record it.
Topic Author
chr
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Re: Insurance asking to repay for services not provided

Post by chr »

Thanks to all again for the great suggestions.

I called the insurance again today. I again got told they were actually not asking me to pay. They tell me they have to send a copy of the letter to me. I pointed out that the letter specifically says that i have to pay and asked again for a written confirmation that i do not have to pay. This time they told me that they are going to ask the claims department to send me a letter. I also asked them to add a note about this in my account. Also I asked for a supervisor who also confirmed they are not trying to get the money from me. This means for now 3 different people from the insurance confirmed to me verbally that I do not need to pay. However the letter is different and only the supervisor acknowledged this.

I am in CA the insurance letters are sent from Iowa. Am I allowed to record phone calls? So far I just took notes each time I called them.

Later today I will call my old dentist again to see why they are not just giving the money back. If they are not willing to do that I might report the fraud. The CA department of Insurance has a form for it.
Thesaints
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Re: Insurance asking to repay for services not provided

Post by Thesaints »

Are you sure you are reading the letter correctly ?
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