Last spring, I had a toothache and went to a dentist for evaluation. The finding was that a wisdom tooth was impacting a back molar and the wisdom tooth needed to be pulled while the molar needed to have a root canal and capped. The dentist forwarded me on to an oral surgeon who was outside of my insurance company’s network group of approved doctors, meaning that my out of pocket expenses would be a little more than if he were in network.

The oral surgeon took an x-ray and found through a CT scan that I had a tumor growing in the sinus cavity behind my cheekbone that needed to be extracted. After getting a second opinion, I opted to have the surgery performed. In addition to the excision of the tumor, the oral surgeon would be removing three wisdom teeth and doing a Septoplasty procedure on my nasal passage which had bone structures growing at wrong angles.

Before the surgery could be performed, the doctor required that I would have to pay for the doctor’s portion of the bill. The receptionist calculated the cost of the doctor’s bill, subtracted the amount that I had already paid on previous visits, and subtracted what she determined that my insurance provider would cover. My out-of-pocket expenses were $4608.00. Knowing that this was what I would need to pay and calculating the hospital’s expense and other miscellaneous expenses that might pop up, I borrowed $10,000. When I paid the oral surgeon’s fee, I asked if this would be all that I would owe and was told yes. I asked once again to make sure, and was told I would not owe anything else.

The surgery was performed and the doctor billed my insurance. My insurance paid substantially less than what I expected for two primary reasons. Rather than billing for one surgery, the oral surgeon billed for three separate procedures. My insurance provider claims that since I did not go under anesthesia three times, they recognize this as only one surgical procedure. The other reason that my insurance provider is not paying off is because they claim, according to a medical billing chart that is used by insurance companies across the U.S. the oral surgeon is charging between 45-60% more than what is the customary and usual charges for the procedures and the area of the country that we live in. Therefore, I am being billed for those outstanding charges to the tune of an extra $2800. Am I obligated to pay the $2800, even though I was told that after I paid the $4608.00, I would not owe any more? Do I have a legal ground to stand on in refusing to pay these excess charges? What are my legal options?

Thank you for your responses.

Was this in writing ?

Also have you appealed the insurance companies ruling, I appeal about 1 in 4 of the insurance companies payments I get and they change about 1 in 3 of the ones I appeal.

Next of course go to the doctor and ask him about refiling his bill.
Now each procedure has a separate code, everything they do is coded by a medical coder in his office, if they did not code properly that needs to be looked at.

And in the end, ask him to reduce his bill or give you a credit.

I ended up having surgary last year at about 30000 bucks, I ended up having about 3000 owed, they cut that amount in half with out any issue when I merely asked them to give me a discout or some credit since I has not able to pay.

And of course in the end, just ask them to set up payments.

As for as having to pay, most agreements on payments is based on estimated insurance payments, if they do not pay as estimated, unless you had a firm agreement in writing, I believe you would have to legally pay. Morally, they should stand by their word.

First mistake never do anything without checking with your insurance provider,next stay within your providers network,always remember that everyone is out to get your money,or save themselves money,you must do the same,unless theirs no choice(emergency room visits) and yes you will have to payoff this bill or it goes into collection,then court,then garnishment.However Fr Chuck is right your personal invovlement early in the process can result in you paying much less than they are asking,but whatever agreement you finally come to, take care of it as promised or else they will void the agreement and take it to court!MO"MONEY!:cool: :eek:

Hi,
I agree with all the other answers you have received.
In addition, the phrase "customary fees" is a rip-off, by insurance companies, as I have had that done to me also.
The only thing you can do is talk with the doctor's office, even talk with him/her, and see if they will lower their fee, nearer to the customary fee.
Many, many doctors charge the insurance company much higher than they should, then settle for what they get, lowering your co-pay to them.
For example, doctors here in my area will charge insurance companies, or submit their bill for $100 for an office visit. The "real" office visit is $70, without insurance!
I do wish you the best of luck, but your only hope is to get the doctor/surgeon to lower his bill to you, making your co-pay less. Either that, or as another stated, have the doctor office re-submit the billing to the insurance, using coding that doesn't contradict each other!