Dental insurance fraud?

Dentist charged more than allowed amount on EOB, in-network, refusing to refund overpayment to patient. What to do?

Thank you for reading in advance🦷🦷.

I had tooth extraction and bone graft done recently. Prior to the service, Dentist A (also the owner) presented me with the estimate fees of $2,340 and noted that insurance would cover $264 for extraction but $0 for bone graft so patient responsibility would be $2,076. My understanding at that time was that her practice was in network – as the dental office verified my insurance when I first went there and they followed EOB for all the prior treatments such as crown, cleaning, filling etc and everything seemed ok.

Extraction and bone graft work were done by another Dentist B (periodontist) in the same dental office and I paid $2,076 upfront with my HSA.

About 10 days later I received the EOB from the insurance and it stated the following:

Dentist submitted: $2,340 Negotiated fees: $1,012 Allowed amount: $1,012 Insurance paid $680.60 Patient responsibility $331.40

Since I’m only responsible for $331.40 based on the EOB, my assumption is that I should get a refund of$1,744.60 (=$2,076 I paid upfront -$331.40 Eob patient responsibility) from the dentist.

HOWEVER,when I spoke with Dentist A (the owner), she said that Dentist B is her consultant, and B’s work as periodontist is specialty and she’s out of network! Dentist A also stated that she filed the claim using her name (A) so that I can still receive some benefits as if she’s doing me a favor. She would only refund about $400 (related to bone graft) for the benefits provided by insurance, instead of $1744.60.

This is very suspicious. First of all, I would never use Dentist B for the work had I known in advance that she is OUT OF network. Dentist A did other work for me previously so i had no clue that another dentist in the same office would be OUT of network. Their office entrance listed both dentists (A is general and B is periodontist)and said “accept major insurance.” It’s worth noting that this particular insurance claim listed Dentist A as both billing dentist and treating dentist. Dentist B’s name was not mentioned in EOB even though she in fact performed the work.

What’s my option? Is it considered insurance fraud since Dentist A did not specify Dentist B is OUT of network prior to work? Even with out of network, I would only need to pay about $800, insurance would pay the rest $1400. But as mentioned, I would not go with out of work (as it uses up maximum so quickly) had I been notified of this in advance. Sadly, it doesn’t feel like an honest transaction.

Will insurance be able to get involved since the claim was already processed and closed? Essentially, Dentist A’s practice is getting $2076 from me and $680 from insurance, totaling $2756 which is also more than the amounts they submitted ($2,340). I’m frustrated.

Thank you in advance!

submitted by /u/RealisticTry3625
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