I've got a little issue with a dentist and an insurance today.

My wife found a dentist that is out of network. My out of network coverage is around 50%. Dentist assured her that he'll be able to adjust insurance claim so that insurance will pay 100%. She was wondering but agreed to the procedures. Dentist performed several procedures in 3 visits. All of these procedures were related to cleaning and healing of gum and pockets between gum and teeth. My wife signed paper with estimate that the procedures would cost $750
which is our liability. But dentist assured once again that we will pay $0.

Today I've received insurance statement with following procedures:
D0150 Comprehensive oral evaluation
D0210 Complex X-Ray Series
D3310 Root canal therapy - Anterior (tooth 07)
D3310 Root canal therapy - Anterior (tooth 08)
D3310 Root canal therapy - Anterior (tooth 09)

Fees charged: 2529. Insurance paid: 714. Our responsibility to the doctor: 1815.

None of root canal procedures have been performed on my wife. She had 3 root canals done about 5 years ago, but none at recent visits.

For me it looks like an insurance fraud.

Now questions:
1. If I report to insurance about the case how insurance will react?
2. What is the lowest amount of the claim to trigger insurance fraud investigation (in case if I report the case to insurance, will they act against the doctor or not?)
3. Was the information from the insurance claim entered into some central medical database and now my wife has 3 records for root canals? How that will affect insurability and premiums in future?
4. Can doctor cancel that claim?
5. In case of claim cancellation, can doctor bill me directly for actual procedures performed?

What would you advise me to do in this situation?

Upd. Quiz: What languages does doctor speak?



April 2017



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