Hello experts!
Here is briefly what happened. My wife had dental surgery in June. We paid a small portion (~$50) of the total ($900) at the desk and the rest was supposed to be covered by insurance. A couple weeks later I've got the bill from the doctor for the rest of the amount ($850) and paid this by cash too, assuming that the insurance payment will come later and they will reimburse me (this already happened a couple years ago).
Then, I've got explanation of benefits from my insurance stating that it paid the doctor about $350 and the rest $500 is write off (goes under provider discount/disallow title).
I called the doctor's office approximately 3 weeks after and they told me that they did not receive anything from insurance, although they are not 100% sure because the checks sometimes (by mistake) could be cashed without a record. I called the insurance and they told me that the check was sent to the doctor's office about 3 weeks ago. They refused to tell me whether the check was cashed or not saying the provider should call them for such an inquire.
Then I called back to the doctor and the receptionist said she will call the insurance but not immediately since she is quite busy working at the desk.
Now, two weeks passed since that day and I did not hear anything from the doctor's office.
Here is my questions:
- how much they should reimburse me (provided that they've got this payment from the insurance), $350 or $850?
- how long they are allowed to delay this?
- I'm going to call the dental office once more, but if they don't seem very cooperative, what should be my further steps?

Thanks!

The amount that the dentist should reimburse you depends on how the $500 is classified. If the $500 is disallowed because it is above the insurance company's pay schedule for this procedure, or because it's counted afgainst your deductible, then the dentist owes you the $350 they received from the insurance company. This is the most likely correct answer. However, if the $500 is disallowed because the dentist is "in network" and the negotiated rate with the dentist for ths procedure is only $350, then in effect the dentist over charged-you and should reimburse you the full $800. So what exactly does the explanation of benefits say about the disallowed $500?

Thanks Ebaines!
The explanation of benefits lists these $500 in "provider discount/disallow" column and gives the following comment:
9A6: The charge exceeds the Delta amount allowed

About the deductible/benefit limits, it says:
Patient has met: $ 316.00 of the $1500 patient maximum for 2010 benefit year
Patient has met: $ 50.00 of the $50.00 patient deductible for 2010 benefit year
On the same page, it says: patient responsibility and co-pay both equal an amount close to $50 (this is normally out of pocket $$)

And these are remaining questions:
- how long they are allowed to delay this?
- I'm going to call the dental office once more, but if they don't seem very cooperative, what should be my further steps or what shall I tell them?

Thanks in advance!

First, was the dentist In-Network? If he was then call Delta and ask whether he's required to accept the insurance payment.

Once you know that you will know how much to ask for in return.

Every dental plan is different. Here in Canada with the Privacy of Information Act the insurance company cannot give any information via phone to anyone but the insured (you).

It sounds like you have a $1500 annual allowance for dental care with a $50 yearly deductible.

Your wife's dental surgery cost $900, the insurance was billed that amount. $50 was deducted from the $900 leaving $850 which the insurance paid $316.00 leaving $534.00 which the insurance did not pay. The insurance sent a cheque to the dentist for $316.00 since the $534 was disallowed because your plan with Delta has a cap on the amount they will pay per procedure.

If you have paid the dentist the full $900 and the insurance is only reimbursing you the $316.00, that is all the dentist has to give you back.

This should be a lesson learned, tough one though, ALWAYS, ALWAYS, ALWAYS ask the dentist to send a predetermination to your insurance provider BEFORE major treatment is done so you know exactly how much you will have to pay out of pocket.

Delta should be willing to provide you a copy of the cleared cheque. If you can't get the person you are talking to to agree to send it ask to speak to his/her supervisor and keep going up the ladder until you get what you are requesting.

I'm not quite sure what you mean by $500 write off. Who is writing the $500 off? Did the dentist agree to do that? (I find that highly unlikely knowing dentists like I do! :))

And a lesson learned not to pay before the insurance pays.

Quote:

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Originally Posted by Fr_Chuck

and a lesson learned not to pay before the insurance pays.

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Unfortunately not always possible. If your dentist is "out of network" he may demand payment in full on the day of the procedure, and it's your responsibility to submit the claim to the insurance company. And then despite indicating on the form that the insurance company should pay the insured, many times they mess up and pay the dentist. I've had it happen to me numerous times. So you then have to get reimbursed by the dentist, just as the OP has in this case. In my experience it typically takes several weeks to sort out.

Thanks for useful info. Especially for advice to call the insurance.

The story did not end. I called insurance today and they confirmed that the provider is in network, and that they should pay me $350 and $500 back. The lady in insurance was very cooperative, they even called to the Doctor office (behind the scene) and found that the check was indeed lost (not cashed). They are going to cancel the previous one and re-issue another check that could take several weeks. Then, if nothing happens I'll call again.

One surprising thing: insurance confirmed that nobody called them from Dr. office as if they were not interested in getting any checks from insurance (although I've notified them about the insurance payment not mentioning the large 'disallow')