Questions Regarding Balance Billing and Excess Payment Issue
Hello everyone. I’m a federal employee and have GEHA dental insurance for my family and me.
In October 2023, my wife underwent a complex dental procedure at an in-network provider, and I was with her during the appointment. At the end of the procedure, the provider’s clerk stated they had confirmed our coverage with GEHA and that our out-of-pocket expense would be $1,644. I paid this amount with a check on the spot, and they processed the payment.
However, about two weeks later, we received the explanation of benefits from GEHA, which indicated that our actual responsibility was only $1,108. This means we overpaid by $536.
Despite multiple attempts, the in-network provider has refused to refund the excess payment, and GEHA has not been able to assist in resolving this issue. This has been an ongoing problem for more than a year now.
Is the provider’s refusal to refund the overpayment against the law, and does it violate their network agreement with GEHA?
If I have grounds for a claim to recover the $536, what should my next steps be? Are there specific actions I can take with GEHA? Would pursuing small claims court be an option? Should I consider threatening the provider with legal action? Additionally, which laws would apply in this situation?
I reside in Louisiana, where consumer protection laws may not be very strong, so I believe federal law could be relevant.
Thank you for any advice or suggestions you can provide!
Hello,
I’m sorry to hear about your experience with the balance billing issue. It can be incredibly frustrating when you overpay for a service, especially when you’ve been told otherwise by the provider. Here are some steps you can consider taking:
Document Everything: Ensure you have all documentation related to the procedure, including the original estimate from the provider, the explanation of benefits (EOB) from GEHA, and any communications you’ve had with both GEHA and the provider regarding the refund request.
Contact GEHA Again: Explain the situation in detail and reference any agreements they have with in-network providers regarding billing practices. Ask them if they can intervene more vigorously this time or advise you on any formal steps you can take.
Request a Written Explanation: If you haven’t already, ask the in-network provider for a written explanation for their refusal to issue a refund. This may help clarify their position and could be useful if you decide to escalate the issue.
State Dental Board and Insurance Commission: You can file a complaint with your state’s dental board or the state insurance commissioner. They may have authority over dental providers and their billing practices.
Small Claims Court: If the provider continues to refuse the refund and you have adequate documentation, small claims court may be a viable option. In Louisiana, you can file a claim for amounts under $5,000 without the need for an attorney. Research your local court’s procedures for filing.
Consider Legal Advice: If the amount is significant or if the provider’s refusal is particularly concerning, consulting with a lawyer who specializes in healthcare or insurance law may provide you with additional strategies and clarify your rights.
Consumer Protection Laws: Federal laws such as the Affordable Care Act offer consumer protections but may not specifically cover every aspect of balance billing. However, many states have laws regulating balance billing that could apply here, so it may be worth looking into Louisiana’s specific regulations.
Seek Mediation Services: Some regions have consumer mediation services for healthcare disputes, which can help facilitate a resolution without going to court.
Finally, when communicating with the provider or GEHA, be persistent but calm. Sometimes, escalation can lead to a resolution. Good luck, and I hope you can resolve this matter soon!