Is it safe? Is it safe?

January 6, 2006 9:32 PM

IANAL Dentist filter: So the dentist told my wife, repeatedly, "of course your insurance will cover this. Don't even worry about it." The insurance won't pay for it. We're stuck with the $400 bill. If we don't pay, our credit is hosed. Non-snarky suggestions?
posted by craniac to law & government (38 comments total)

Can we take this guy to small claims court? He did a restorative/cosmetic procedure on my wife's front teeth. He totally brought it up, pushed the work, etc. repeatedly told her it was routinely covered by insurance, and now they have started billing us after the insurance company refused to cover it.

Arrrghh.
posted by craniac at 9:34 PM on January 6, 2006

>> Can we take this guy to small claims court?

My experience with small claims court can be summed up with:

* Anyone can sue anyone for anything.
* They can win for nearly random reasons.
* Good luck getting anyone to actually pay the judgment.

$400 bucks ... even if he loses, the dentist may just scoff at it. That might be just two rounds of golf he'll do without this month.

That being said, there is a certain je nais se quois to a summons that might spur someone into action.
posted by frogan at 9:47 PM on January 6, 2006

What if she wrote a firm but professional letter, along the lines of "at your suggestion, I consented to this procedure only after your repeated reassurances that it would be covered by my insurance plan. I would not have consented to the procedure without this assurances from you, which I trusted to be made in good faith and based on adequate previous experience in matters of billing my insurance plan for this same procedure. If we cannot reach a resolution, I will take my care to a dentist who has more experience and a better understanding of what is and is not covered by my particular plan."

It may or may not work; brace yourself to have to pay the damn $400 anyway.
posted by scody at 9:50 PM on January 6, 2006

The filing fee is $45. Already, you can't recoup more than $355.
posted by oaf at 9:52 PM on January 6, 2006

(...and if you lose, you're out the $45...)
posted by oaf at 9:53 PM on January 6, 2006

I second what scody said; in addition, perhaps you could even meet the dentist halfway -- see if he would be willing to cut the bill in half. Perhaps not fair, but I'd rather be on the hook for $200 than $400. Good luck.
posted by davidmsc at 9:55 PM on January 6, 2006

You might have better luck taking this up with a professional association or state licensing board than in court; IANAL, but your legal case sounds weak to me. If you were worried about your insurance covering it, why didn't you ask them? Even if your dentist was correct that this is routinely covered, that still tells you nothing about your own insurance coverage, and I suspect a judge will feel that it was your responsibility to figure this out.

OTOH, a licensing board might be sympathetic to the arguement that your dentist should not be engaging in uninformed speculation as to what your insurance might or might not cover when he stands to make money off of the procedure. Even here I doubt your chances of having him disciplined are that great, but maybe he'll decide it's worth writing off the $400 rather than dealing with them.
posted by IshmaelGraves at 9:57 PM on January 6, 2006

Honestly, I can't think of any reason why you wouldn't be obligated to pay the bill. This is not a snark, it's just the truth. It's not your dentist's responsibility to accurately guess what your insurance company will pay for. Besides, as far as you know, maybe he *does* have experience indicating that insurance companies tend to pay for it. But even if he doesn't, it's not his problem.

On preview:

"...If we cannot reach a resolution, I will take my care to a dentist who has more experience and a better understanding of what is and is not covered by my particular plan."

This is crazy. Your dentist has more responsibility to check the air in your tires than he does to do this. If you want to know what your insurance plan covers, call your insurance company.
posted by bingo at 9:58 PM on January 6, 2006

In my opinion, he was hard selling the procedure and lied to do it. I think we'll go for the letter, and talk to the licensing body. I agree we should have looked into it. As a general rule of thumb, the dentists with the most expensive offices and latest gadgets (tv goggles, etc) tend to get really aggressive about selling whitening and other non-insured services.
posted by craniac at 10:07 PM on January 6, 2006

Oh, and we haven't paid him yet. And I was thinking if we went to small claims court, then we could show the judgement to any collection agencies he might employ.
posted by craniac at 10:14 PM on January 6, 2006

"...If we cannot reach a resolution, I will take my care to a dentist who has more experience and a better understanding of what is and is not covered by my particular plan."

This is crazy. Your dentist has more responsibility to check the air in your tires than he does to do this. If you want to know what your insurance plan covers, call your insurance company.

Then I guess my own dentist and doctors are crazy, because they -- or, more accurately I suppose, their office managers -- routinely determine ahead of time what my plan will and won't pay for in the case of expensive, elective procedures.
posted by scody at 10:15 PM on January 6, 2006

Besides, especially in light of craniac's feeling that the dentist was giving the hard sell and lied about the insurance's likelihood of covering the procedure, it's a polite way of calling him out to say, basically, "I'm going to find someone who won't bullshit about what's likely to be covered just to make a sale."
posted by scody at 10:18 PM on January 6, 2006

Some dentists let financially strapped patients pay off their bills by installments. Perhaps this one would be agreeable, given the extenuating circumstances. You wouldn't have the satisfaction of suing him, but you wouldn't have the stress either.
posted by GoatCactus at 10:19 PM on January 6, 2006

Dental insurance is basically a savings plan, rather than a risk pool, as such, I don't think there is much variation in what different plans do or do not cover.

I agree that it's really your responsibility to find out what they cover. On the other hand, he sounds like he was quite happy to offer his informed opinion.
posted by Good Brain at 10:19 PM on January 6, 2006

Technically speaking, it is your responsibility to check what your insurance plan covers. Different people have different levels of insurance coverage, so there is no way a dentist would know (or be expected to know) what your specific plan covers. Therefore, if you take it to court, you may not win.

A polite letter to the the dentist may be the best option.
posted by madman at 10:21 PM on January 6, 2006

Having done medical billing, I know that doctors offices will always say that it is your responsibility to know what your insurance will and won't pay for. That said, it was unprofessional of your dentist to make that assumption without actually checking with your insurance agency.

Here's the little-known truth about medical billing: doctors rarely recoup the full "fee" for a procedure. Often they'll bill insurance for the listed price , the insurance will pay a portion and then determine what the patient should pay and then not pay. So even if the price is listed as $400, they may not get more than $200 normally from the total of insurance plus patient payment...My point is that you should call the dentists office and ask to talk to the billing person. Calmly explain your situation, and ask if they can adjust your bill. Then ask if you can pay in installments. If you're nice but firm, you can usually get them to knock it down.
posted by radioamy at 11:11 PM on January 6, 2006

Call around to insurance companies and ask if the procedure is routinely covered. If not, you'll have some evidence to support the argument that the dentist was lying to sell a procedure.
posted by stefanie at 12:19 AM on January 7, 2006

From my days working in credit years ago (not a lawyer, but yes, a former collector...)

Dentist offices do not report to credit reporting agencies.
Not all medical/dental collection agencies report. Some do, some don't.

Small claims court, conciliation court--if there is a judgment against you, that will definitely show up. Plus, if you are taken to court, you could end up paying not just the original $400, but court and collection agency fees on top of that. And although frogan's experience is correct--individuals do have a tough time collecting on judgments--collection agencies have more experience and resources to apply to the process.

I would try to negotiate. If unsuccessful, I'd pay the $400, grumble, and find a different dentist.

Any activities at the licensing board would not have any effect on your obligation to pay. You could still be taken to court and they could still get a judgment against you.
posted by gimonca at 12:19 AM on January 7, 2006

i'm with radioamy...talk to them, and then do a payment plan.
posted by amberglow at 12:36 AM on January 7, 2006

It is your responsibility to know what your insurer will pay for, certainly. That said, who among us is going to actually whip out our cell phone while sitting in the dentist's chair to call the insurer and confirm coverage? Especially if (as is often the case) we didn't know what procedure was going to be recommended until then?

My dentists have pretty much always called the insurance company to find out how much they'll be paid, then told me what I was responsible for. This guy is highly unprofessional. At the least, take your teeth elsewhaere next time.
posted by Kirth Gerson at 3:11 AM on January 7, 2006

Knowing your coverage is your responsibility, unless you have managed care and the dentist was a contracted doctor in the plan, which does not appear to be your situation. However, the dentist used what would appear to be unfair persuasion techniques to convince your wife to have a procedure. If the dentist knew that insurance likely would not cover it but said these things anyway then perhaps it was fraud. My guess is that the dentist knew full well that most insurance would not cover the procedure. The feared response to a billing request - a charge of malpractice. You have not indicated any unhappiness with the procedure itself. However, perhaps the high pressure sales is similar. I am sure the dentist would like neither of these reported to the dental licensing board. Perhaps you can reach an accommodation, but I would not make any overt threats about reporting, but would rather discuss how unfair the tactic was and suggest that you might want further clarification on such techniques from the board. Small claims is a decent route to go as many cases are decided in the plaintiff's favor merely based upon the defendant failing to show up. When they do the baby is routinely cut in two. Once you get a decision which requires you to pay, even a reduced fee, the list of horribles which could befall you for failing to pay increases. Someone suggested above good luck collecting. My guess is you have the $, not the dentist. A win means you keep it and he can not send it to collections. If all else fails your wife has nice looking teeth, and you have both learned a nasty little lesson for not that much money. If you do have to pay, you can still later report this crook to the dental licensing board.
posted by caddis at 5:24 AM on January 7, 2006

Have you contacted your insurance company regarding the submitted claim? Maybe the mistake is theirs.

I'm currently battling my insurance company to pay for a routine cleaning. First time claim was received, they rejected because I wasn't in their system yet. I was just added to my husband's plan and they didn't have that information yet.

The second time claim was sent, they rejected it because they had already considered that treatment with the prior claim. The third time, after a phone call to them, the claim was run through their system again, this time they do recognize that I am covered, however, now they rejected the claim because they think I've used up my $1000 annual benefits, even though this is the first time I've tried to bill them.(for $203)
posted by Jazz Hands at 6:13 AM on January 7, 2006

there is a whole subculture of dentistry which cultivates the ripoff. they have books on ripoff techniques and meet for ripoff symposia. "implants" are one of the telltale signs. dentists who push implants likely have some book lying around with a euphemistic title such as "99 ways to increase the profitability of your dental practice." these books are full of methods on how to fleece both patients and insurance companies. they play one off the other.

you are out $400. pay it. but get vengence. make it your hobby for the next few month to report this crook to business and professional boards. dentists who engage in these sorts of practices often have all kinds of scams going on at once, and often end up in court themselves. they really don't care about their own reputations. but when they finally wind up in court, you can do your part to see there is no one there to speak favorably on their behalf. you can even find the consumer protection division of your state attorney's office and file a fraud complaint. often actions on such complaints are a result of a critical mass of complaints being filed. someone with a history of complaints is more likely to prompt an investigation.

look at it this way, the more people hesitate to speak up about these practices, the more likely it is these practices will continue to perpetrate the same thing which happened to you on somebody else.
posted by 3.2.3 at 6:14 AM on January 7, 2006

Also, you say insurance didn't pay, but what was the reason?

Were you out of benefits for the calendar year? Paying for the treatment might not have been denied, just that you had no more coverage available, which happens to a lot of people near the end of the year.
posted by Jazz Hands at 6:19 AM on January 7, 2006

I had a similar situation when I was newly married and poor. My wife's dentist since she was a child did the exact same thing, on a routine (covered) check-up, he decided that she needed a certain procedure that ended up not being covered.

This was 9 years ago, and I wish I had done more. But I asked them to waive it since he didn't even present it as extra to the check-up. No luck. I asked if they could take the amount that the insurance would have paid, like $350 instead of $600, and let us do payment plans. No dice. Finally I just paid and never went back to the wanker.

If I had it to do over, I'd still pay the amount, so that my credit would be unaffected, but I'd send a firm letter saying that I am paying just to preserve my credit rating, but that I believe things were not done completely ethically and I will be reporting the situation to all appropriate agencies if I cannot reserve a discount with the dentists' office first.

If they just won't do a thing for you, report to all those places, and maybe you'll at least get some satisfaction for all that money you spent. And, and if you have a blog, write about the situation using names. Bad web publicity is more and more important these days, and then their shady behavior will end up costing them more than it made them.
posted by visual mechanic at 6:36 AM on January 7, 2006

By the way, in my situation, the dentist did the extra procedure during the check-up, seconds after he brought up the need for it. I never even got to talk to my wife about it, and we had no time to check to see if we had coverage. My wife just thought it was part of the check-up.
posted by visual mechanic at 6:39 AM on January 7, 2006

IANAL, but I think there's an argument for a promissory estopel claim against the dentist. The dentist made a promise which was resonably relied on by the patient. Essentially, you were assured that the treatment was covered, and only after recieving such an assurance did you consent to the procedure.

Of course, as others have noted, the dentist will claim that it is the patient's responsibility to know what is and is not covered in advance. There may be merit to this if the procedure were routine, or if you'd had it done before; however, to expect a patient to know the full scope of coverage for every possible medical ailment seems unreasonable to me. Quickly, imagine all the things that could go wrong with the human body and now tell me, without checking your policy, what corrective procedure is and is not covered. This is the decision we're asking patients to make, on the fly, in a compromised position on the examining table or dental chair, if we apply blanket responsiblity on the patient.

I'd argue that in this instance the dentist is in the better position to know whether or not a procedure is or isn't covered. The dentist sees lots of patients, deals with lots of insurance plans, and from experience probably knows which procedures are and are not typically covered. Furthermore, the dentist likely had contact information for your insurance plan; asking the receptionist to place a simple phone call would avoided this whole situation in five minutes or less. Instead, the dentist gave you the assurance that the procedure would be covered. Why wouldn't you believe the professional advice given?

The dentist could also argue that, even with the given assurance, it was unreasonable to rely on the promise. Had the language been, "you might be covered" or "you should check to see if your insurance covers this" then I think the dentist would have the stronger position. But having assured the patient that "of course insurance will cover it. don't worry" the dentist's statement seemed to have been ment to induce your consent.

Of course, there could be hidden minefields in your claim -- suppose your insurance policy was the distinct minority that did not cover the procedure; or worse, you opted out of such coverage for whatever reason even in your particular policy though your insurance provider typically covers the procedure. Or perhaps you signed some sort of waiver at the start of the visit which may absolve the dentist of any obligation in this area.

Write a polite, but firm letter (after all, before you charge in to court it's probably a good idea to have attempted to settle the dispute reasonably) explaining your situation/side of the story and see what happens. Methinks a trip to court for $400 on a solid, but hardly airtight, claim may not be worth the aggrivation it creates. But who am I to tell you how to exercise your rights?

Good luck!
posted by herc at 7:26 AM on January 7, 2006

On a re-read of the thread, other posters seem to make a very good point -- discover why your insurance won't cover the claim first before focusing your attention toward the dentist. After all, you'd hate to have egg on your face if you discover that the fault was your own!
posted by herc at 7:33 AM on January 7, 2006

One other thing, you definitely should call your insurance about this too. I've found that, unfortunately in my case, insurance companies seems to decline just about everything expensive the first time they receive the bill, and hope that you just pay on your own. This has happened to me 5 different times. Each time I've had to call them and challenge and then they pay up eventually. This might be a case where it's not the dentist but the insurance company that needs to be questioned.
posted by visual mechanic at 8:23 AM on January 7, 2006

I am a lawyer. This is not legal advice, and I am not YOUR lawyer. I offer this for info-tainment purpsoes only.

In my opinion, your doctor's behavior satisifes the basic elements for a fraud claim. Regardless of whether you had a duty to know what your insurance covered or not, your dentist, acting from a position of superior authority, made an affirmative misrepresentation to you to induce you to act in a certain way. You, justifiably relying on that representation (justifiable reliance is the key element here -- many will disagree with me on whether you were justified in taking the dentist's word in this) chose to follow the dentist's advice and have the procedure. Based on that, I think you have a legitimate argument that your dentist engaged in fraudulent activity.

The reliance issue comes down to whether a reasonable person, in your shoes, would have done what you did. And I think that a reasonable person would be justified in accepting the opinion of a medical practitioner, who handles and accepts insurance claims on a very regular basis -- indeed, as a core part of his ability to provide you with dental services -- when he tells you that (in his experience) claims such as yours are covered.

The dentist could have (and should have) completely refused to offer an opinion, and told you to investigate your own coverage. But he didn't. He, in an attempt to get you to perform a costly procedure, made a representation to you to induce you to act. Had you investigated the coverage on your own, you would have likely reached a different conclusion, and possibly decided to forego the procedure. The dentist, however, shortcut your analysis of your coverage by making a misrepresentation to you that harmed you. I think this is a clear example of fraud.

Now, obviously, just because the dentist acted improperly doesn't mean you can collect. It's going to cost you money to file a small claim action, and your costs will likely offset any recovery you are likely to obtain. If it were me, I would
- write a strongly worded letter, explaining the scenario
- ask him to resolve the situation peacefully
- accept a reasonable discount off the full bill (say, offer to pay $100 - $200)
- if that doesn't work, prepare a small claims complaint, attach it to a letter, send it to him again, and give him a deadline to respond before you file. This may get his attention.

Again, this is just my opinion. Again, I am not offering to act as your lawyer in this matter. Many other good lawyers will disagree with me. Still, I do not think you are required to pay the full $400 in this situation.

Good luck.
posted by fearless_yakov at 9:11 AM on January 7, 2006

Is your dentist associated with the insurance company? File a complaint with the insurance company, stating your side of the case. I *threatened* to do this to a dentist who claimed I owed $1500 to him, in a letter addressed to him (said, "For Dr. XXX's eyes ONLY") on the outside of the envelope. It stated what we had been told by him and his office staff, what the insurance said was not covered, and that we were going to report him to the insurance company and state dental board.

I put the letter in the mail on Wednesday, we received his reply with his signature on Friday, absolving us of the $1500 debt. It kind of shocked me, actually.
posted by Doohickie at 9:19 AM on January 7, 2006

Then I guess my own dentist and doctors are crazy, because they -- or, more accurately I suppose, their office managers -- routinely determine ahead of time what my plan will and won't pay for in the case of expensive, elective procedures.

They're not crazy. They're just doing you a favor. They're also doing themselves a favor, because if they don't do something for you that your insurance doesn't cover, then they don't have to worry about getting you to pay directly, or about the sort of negative reputation that craniac's dentist may bring upon himself. Don't get me wrong, those concerns on the part of the doctor's office are valid. But they are not *obligations*.

A lot of comments above say something to the effect of "what are you supposed to do when a doctor recommends a procedure in the middle of your visit...get up from the examining table and call your insurance company?"

Well, it's not that simple. If you do trust your doctor, and he recommends a procedure for the sake of your health, then you should probably consent to it, whether you end up paying out-of-pocket or not. And that should be the doctor's priority as well: it's his job to tell you what you need, not what your insurance will pay for (damn it, Jim, I'm a doctor, not a medical insurance auditor, etc. etc.).

Recently, my orthopaedist, whom I trust (as a doctor) told me that I needed an MRI. He actually mentioned that my insurance would pay for it, too. I hope he's right about my insurance paying for it (this all happened very recently), but even if he was wrong, that's immaterial to the fact that *he's my doctor, and he recommended a procedure that he thought I needed, based on his medical knowledge*. If my insurance company doesn't pay, I'm not going to be angry with him. I would only be angry with him if his recommendation to have the MRI turned out to be without merit.

In craniac's case, we're talking about something different: a "restorative/cosmetic procedure." Doesn't sound to me like this was really necessary to maintain the patient's dental health. If craniac's wife only wanted the procedure if her insurance paid for it, then yes, she should have told the dentist she'd check with her insurance company first. I understand that the dentist is not a nice guy and that less-than-assertive patients are at a disadvantage here. I think craniac's wife's dentist is a jerk, and I wouldn't want him to be my dentist. But that doesn't change the fact that it technically isn't his responsibility to keep track of what your insurance will pay for and what it won't.

On preview: I'm not a lawyer, and fearless_yakov is, but he says the reliance issue comes down to whether a reasonable person, in your shoes, would have done what you did, and I guess it's obvious at this point what I think a 'reasonable person' would have done (setting aside the fact that the idea of 'a reasonable person' is bunk to begin with, etc. etc.). Maybe a court of law would disagree with me.
posted by bingo at 9:55 AM on January 7, 2006

I am not a dentist. I manage a dental office. We get these types of things all the time. We file claims for our patients as a courtesy, taking all of our payment at time of service. When a patient has a need or desire to get work done we file what is called a predetermination. The insurance company sends to us and the patient an explanation of benefits. This form shows how much the insurance company thinks is reasonable, and this number varies wildly wildly from one insurance company to another. We discuss this with the patient and have them sign a treatment plan, which acknowledges the prescribed treatment and that the prices for those procedures are valid for thirty days from the date of the plan. (This protects us from patients who wait X number of months to schedule a filling only to then have such deterioration that a more substantial filling or even a crown is necessary.) This form and the insurance papers are kept in the patient's chart.

I cannot even begin to guess why your dentist did not have you sign a treatment plan for a $400 procedure, nor why they wouldn't get an EOB (explanation of benefits) beforehand.

Despite the lengths we go to for our patients, I have to agree that ultimately, it's the patient's responsibility to find out what is actually covered. For instance, sometimes we get an EOB and then the patient gets the work done after they've cancelled their insurance plan. There is no way they will be reimbursed. Another thing that happens is their benefit year is not the same as a calendar year, whcih causes confusion. It also says on the EOB that it is nota guarantee of payment, and htat the patieint's contract will prevail in matters of payment.

I am also left wondering what exactly this procedure was (mostly out of curiosity). It doesn't sound like veneers (cause that's about $1,000 per unit) and if it were fillings it might have just been miscoded, or you could have been over your plan limit for the year, as has been mentioned already. I also don't know how many of your wife's teeth were worked on, and whether top or bottom.
posted by bilabial at 2:36 PM on January 7, 2006

You still have your $. It's the doc who'd have to go to small claims. Call your insurance company and discuss it with them. They'll probably say it's not covered. Write a very friendly letter explaining that you relied on his assurance that it would be covered, it's not covered, it was likely he'd know it was not covered, and you'd like to come to an amicable resolution. At best, since you got the benefit of the treatment, you might want to pay for half. But negotiate before you reveal what you're willing to pay. Get a new dentist; this one sounds unprofessional, and neither of you is likely to want to see the other again.
posted by theora55 at 3:23 PM on January 7, 2006

Speaking solely as a consumer of medical and dental services, every time that I have been in a situation where I am about to receive some kind of treatment, and my insurance coverage for that treatment is in doubt, the office staff has called my insurer to check (and usually discover than no, I'm not covered). This is true both in cases where I think I'm covered and where the doctor/dentist/staff thinks I'm covered.

So I'd be very surprised if a medical practitioner just glossed over that question. Depending on what mood I was in, I'd either insist that his staff check, or shrug and decide "he must know something that I don't."

That is, until reading this thread.

I was once in a situation where my insurance company denied a claim for a medically necessary, emergency procedure, saying the doctor charged too much. My doctor's staff went to bat on my behalf and tried to justify it to my insurer, to no avail. They wound up seeking payment from me, but drastically reduced the bill, which I paid.
posted by adamrice at 4:00 PM on January 7, 2006

By the way, under HIPPA your dentist is probably not allowed to report your bill to any collection agencies. He'll need to get a judgment in order collect any money.

I say probably, because no one actually knows what's in HIPPA, but hospitals can't even bill your insurance provider without a waver.

If you already wrote a waver, you can rescind your wavers in writing. So add something to your letter like "This letter constitutes a written notice under HIPPA that you many not divulge any medical information to any persons or parties for any reason, and any previous wavers are recinded".
posted by delmoi at 4:55 PM on January 7, 2006

HIPAA will not prevent the bill from going to collection.
posted by caddis at 5:46 PM on January 7, 2006

By the way, under HIPPA your dentist is probably not allowed to report your bill to any collection agencies. He'll need to get a judgment in order collect any money. Do you mean credit reporting agency rather than collection agency here?

Doctors/dentists do not typically report to credit reporting agencies anyway.

A collection agency could easily report "This person owes us $400, it's six months past due" without divulging the nature of the debt, who the original creditor was, etc.
posted by gimonca at 10:35 AM on January 8, 2006