Insurance Scare or Scam? Need Advice!
Hello everyone, I’m seeking some advice on a frustrating situation I’ve been dealing with. I recently visited my orthodontist for a wisdom teeth extraction, which is covered by my insurance since they’re in-network. I was charged a $200 consultation fee, which I know isn’t covered by insurance. They informed me that my insurance wouldn’t cover the procedure initially, so I paid upfront with the understanding that they would submit a claim and reimburse me if it turned out to be covered.
After my surgery and recovery, I called the insurance company two weeks later only to discover that no claim had been filed. To my surprise, they confirmed that my insurance actually does cover both the extraction and the bone graft. I’m only supposed to pay 20%, while insurance covers 80%.
I contacted the orthodontist’s office to ask them to submit a claim since they are in-network. The front desk staff said they would communicate this to the billing department. Days passed, and still no claim was submitted. Frustrated, I began calling daily until I finally saw a claim filed after two weeks of persistent follow-up.
Here’s the kicker: I paid $5,356 out of pocket—$5,000 for two bone grafts, $268 for the extractions, and $88 for anesthesia. However, when I checked what the office submitted, they filed a claim for a completely different procedure that my insurance doesn’t cover!
I genuinely feel like this office is trying to take advantage of me. I reached out to the oral surgery department at my insurance, and they contacted the orthodontist to confirm my actual treatment, advising them to submit a new claim for the correct procedure. They told me to wait a week, and if nothing changes, I should call back to file a formal complaint.
I’m anxious and just want my money back. I’ve definitely learned my lesson and won’t pay upfront for services that should be covered by insurance again. Any advice on how to navigate this situation would be greatly appreciated!
It sounds like you’re dealing with a really frustrating situation, and it’s understandable to feel anxious about it. Here are a few steps you can take to address the issue:
Document Everything: Keep a detailed record of all communications you’ve had with both your orthodontist’s office and your insurance company. This includes dates, times, who you spoke with, and what was discussed. This documentation will be crucial if you need to escalate your complaint.
Follow Up with Your Insurance: Since your insurance company has already confirmed that the procedure is covered, make sure to stay in touch with them. If the orthodontist’s office hasn’t filed the claim correctly by the time the week is up, reach out again to reiterate the issue.
Escalate the Claim: If no progress is made with the orthodontist office, ask your insurance company to assist you further. They may have protocol for dealing with this kind of situation, and their involvement might push the orthodontist to act more quickly.
File a formal complaint: If you still don’t see any movement after a week, proceed with filing a formal complaint as advised by your insurance. You can also consider filing a complaint with your state’s dental board or the Better Business Bureau.
Reach out to your state’s insurance commissioner: If the situation does not improve, consider contacting your state’s insurance commissioner. They can provide guidance and may be able to investigate the matter further.
Payment Methods: For future procedures, you could consider discussing payment options clearly beforehand, asking about insurance billing processes, and ensuring that you’re aware of what will be covered before paying out of pocket.
It’s unfortunate that you had to go through this process, and learning your lesson is certainly a tough way to gain experience. Stay persistent, and hopefully, you’ll get the resolution you deserve. Good luck!