Dental Insurance – Provider says nothing was covered, insurance never received a claim
Is anybody aware of why this provider would bill like this?
I was referred to an out-of-network endodontist. I have a PPO and have 100% coverage for endodontics with a $50 deductible up to $1,500 per service (tooth basically) with Anthem. I've seen plenty out-of-network providers with no issues.
I call to schedule and they tell me they're out of network, but can fit me in the next day. I call my insurance and they confirm my coverage. This is where things get weird.
I get a call from their insurance coordinator within an hour of scheduling and she says she confirmed with Anthem and my out-of-pocket will be $400 which is the 100% of cost of the consult. I know insurance doesn't always shake out perfectly with coverage and the most accurate way to estimate is with the codes which I didn't have from them. I'm lucky that I can afford it and decide I'll see what actually comes back when they submit the claim.
They send me the link to their registration portal and unlike most people, I read the fine print. It says they will not submit a claim to out-of-network insurance and that I will be expected to pay the cost upfront the day of my visit. They will provide me with all the documentation I need to submit to my insurer. I have actually had to do this before so I rock up prepared to ask for an itemized receipt.
When I check out, they say that they filed a claim with Anthem and Anthem is not covering any of the cost and my portion is the full $400. I'm skeptical that my insurance reviewed the claim within either 1 hour of my checking in to my appointment or 24 hours of me scheduling the appointment if they went for pre-approval, but whatever. I pay and ask for my itemized receipt. Right at the bottom, they've listed Anthem Claim # 12345.
I go back to my office and log in to my insurance portal. I am always able to review all my claims there, and don't have one by them. I call to confirm if one was submitted, since their fine print indicates they don't submit these claims. They had not yet received one. 2 business days later they still haven't. While I was on the phone with them, I reviewed the codes with them and I am covered. My out-of-pocket costs should end up being around $78 when I submit my claim direct to them, which I am doing.
I really want to know, though, WHY a provider would operate like this?
I'm not super knowledgeable about how providers are paid by insurance, but surely requiring payment upfront like their written policy indicates ensures that they are compensated. I see no need to claim my insurance denied coverage if the intent was always to bill me upfront and have me submit retroactively? It just seems really weird.
submitted by /u/CoralAccidental
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