How can I get out of a bogus medical bill?
September 13, 2010 5:49 PM   Subscribe

My dental insurer made a mistake and I am stuck with the $3,200 bill. How can I get out of it?

My wife and I needed our wisdom teeth taken out so we went to an oral surgeon for a consultation. We were examined and the oral surgeon's office called Aetna (our dental insurance provider) on our behalf to find out what kind of coverage we had. The girl at the oral surgeon's office followed a detailed tooth-by-tooth form and the rep from Aetna provided detailed information on how much of each part of the procedure would be covered. The difference was around $600 which we gladly decided to pay and go forward with the procedure.

I clearly asked whether we would receive any additional bills and we were assured that we would not. Well, 2 months, a lot of suffering, and 8 less teeth later we get a bill from the oral surgeon for about $3,200. Aetna claims that my dental insurance does not cover any extractions whatsoever. I later discovered that this is correct but I was not aware of this at the time since it had never come up and a professional oral surgeon's office just called on our behalf and got the details from Aetna. So why would I ever question that?

Aetna declined the coverage after telling the oral surgeon's office all kinds of detailed numbers they said they would cover (I have a copy of the form with the numbers the girl at the oral surgeon's office was told, as well as written testimony) and I am stuck with a bogus bill. I went through both levels of Aetna's appeals procedure with no luck; Aetna is saying that since the insurance does not cover the procudure that I must pay the cost. Further, they have a record of the call from the oral surgeon but claim they did not tell them any numbers whatsoever and that they informed the oral surgeon's office that we had no coverage and to charge their PTO rates.

My questions are thus: how best can I fight this bill and have Aetna cover their mistake? If all else fails, we live in the US now and are planning to move to Canada next year. Any idea what will happen if we simply don't pay it? Can we somehow be pursued out of the country for that? The oral surgeon is being very cooperative and is stopping the bill from going to a collection agency for me, but it seems to me the problem should be between them and Aetna, but somehow it's not.

While I want this situation to have been resolved a long time ago I'm willing to put time in on it; I would have to work a lot of hours to make $3,200 and I'd rather spend the time screwing Aetna because this is far from the first time they've pulled this kind of self-contradicting nonsense on me.

Through a bit of social engineering I managed to speak to an "executive resolution" person at Aetna but all they said they would do is examine my policy and check their phone records, neither of which help me at all since Aetna has no record of this mistake. My attourney advises me that the next step would be arbitration or small claims court, but I'm highly frustrated by the situation and would love to hear what insight Mefites might provide. Thanks!
posted by tmason to Health & Fitness (30 answers total) 4 users marked this as a favorite
Where is Aetna's response to the form submitted by the surgeon's office? There should be some paper trail there, right? And that would start at the oral surgeon's office. Otherwise, it sounds like the only mistake here is that you didn't read your insurance policy before having work done. If I were you, I would talk to the oral surgeon and see if you could work out a payment plan.
posted by Cat Pie Hurts at 5:57 PM on September 13, 2010

My opinion is that it was your responsibility to understand your medical/dental coverage. I know that sounds a bit harsh, but, given the state of health care in this country, making the assumption that ANYONE will look out for your best interest is risky.

And, truth be told, you have no idea what Aetna told the girl at the office. And, if she is willing to state that she told you it would be covered, perhaps the dental office should pick up some of that cost (or all of it).
posted by HuronBob at 5:59 PM on September 13, 2010

So Aetna says they have a recording of the call with your surgeon's office, and that they did not provide numbers. But your surgeon's office says they did - and even gave you the specific numbers.

One of them is lying - if Aetna's claim is true, seems like they'd hand over the recording to you. I'm not lawyer but it seems like that would also be discoverable in a trial?
posted by RustyBrooks at 6:01 PM on September 13, 2010 [4 favorites]

What part of the bill is bogus? As you describe it, the surgeon charged you the going rate for a necessary medical procedure. If you had somehow found out ahead of time that your policy didn't cover extractions, would you have gone without removing your wisdom teeth? It sounds like all you're out now is the pain of realization and not any actual funds.

My advice would be to pay the bill, before you sink more money into late fees/interest charges, and paying your attorney.
posted by Pomo at 6:03 PM on September 13, 2010

I have to agree with HuronBob, you should have known what your dental insurance would cover. Whether any promises were made on the phone from Aetna to the surgeon is sort of a moot point. I think your best option is to work with the surgeon's office for a lower bill; perhaps they can charge you what they would have charged insurance if it were covered.
posted by contessa at 6:05 PM on September 13, 2010

I used to manage a dental office. We always made it very very clear that pre-authorization was something we were happy to do as a courtesy to our patients but that responsibility for the total amount of any procedure was ultimately on the patient's end.

Which was to say, if your insurance pays, great for everyone. If your insurance refuses to pay, the office is still expecting to get paid. They did the work for you, not for your insurance company.

You, as a customer of your insurance company, and as a customer of your dentist, are responsible for knowing the limits and conditions of your coverage.

Yes, I realize that insurance companies make policies unclear, but that's not your dentist's fault.
posted by bilabial at 6:06 PM on September 13, 2010

Piling on: If your policy says it's not covered, there's very little magic that will make it happen after the fact. "But they said" is usually superseded by the written contract that is your policy.
posted by sageleaf at 6:10 PM on September 13, 2010

If you flee to Canada, there's not much anyone can do--$3,200 isn't worth pursuing across a border, and there's no unified credit reporting between Canada and the U.S. The last time I was involved in cross-border credit, it was explicitly stated to me that they don't and won't check across the border.

However, be aware here that the person getting screwed if you flee isn't Aetna, it's the oral surgeon. He's the one not getting paid either by Aetna or you.
posted by fatbird at 6:11 PM on September 13, 2010

In the words of my dentist's office manager: "most dental insurance is as close to a legal scam as you can get away with in this country, and they will do anything they can not to cover your care and not to pay the dentist. And they've invariably got the fine print on their side." This is how two crowns I expected to pay $1100 for (based on pre-authorization estimates) wound up costing me $3600+ a few months ago (even after my dentist himself personally appealed to the insurance on my behalf). My dentist is amazing and does brilliant work, so I didn't consider for a second not paying the bill -- as others have said, he's the one who'd get screwed, not my shitty dental company.

Honestly, I don't know anyone with good dental insurance that actually pays a decent proportion of what anyone thinks they should pay. Hell, I have a good friend who works in the health insurance industry (we have some interesting conversations, he and I!) and he rants about how crooked dental insurance is.
posted by scody at 6:19 PM on September 13, 2010 [1 favorite]

I'm not your lawyer, but you might want to check out the elements of fraudulent inducement in your jurisdiction.

also you might be able to subpoena the records (paper and any recordings) of Aetna from that conversation with the dental clinic. If I were you I'd want to see for myself what those records show

and, find out if you signed any sort of financial responsibility agreement with the dentist
posted by wurly at 6:19 PM on September 13, 2010 [1 favorite]

Something like this happened to me - the assistant called my insurance company to find out how much a root canal would cost, only to be charged way more when it turned out it wasn't actually covered. In my case, it was because I wasn't passed the waiting period.

My guess is that the dentist's office called your insurance company, found out you weren't covered, then made a different call (probably to a different department) to get the standard prices that Aetna charges if you were covered, based on their relationship with your dentist. But those numbers have nothing to do with your policy. You saw her make the call, so you you're convinced that the insurance company is lying to you, so when you get the real bill, you blame them and not the dentist.
posted by AlsoMike at 6:30 PM on September 13, 2010

If the oral surgeon has records of the phone calls or whatever other exchanges they had with Aetna, and they should have some records, get copies of those. They might help.

If you could, I hope you'll fight this. Otherwise there's no incentive for dental insurers to do better.
posted by amtho at 6:30 PM on September 13, 2010

Response by poster: The letter I have from the oral surgeon states that their office requested, from Aetna, specific codes for coverage and that they were given exact amounts that Aetna would pay them. (I have a copy of the form with these numbers on it). The oral surgeon's office maintains that "we were never told there was no coverage for these services".

I have that evidence but Aetna's word directly contradicts it. According to the surgeon Aetna gave out all of these numbers (evidenced by the form) but according to Aetna no numbers were given out. Yet both sides have a record of the call. So who made up the numbers?

I have been fighting this and fully intend to continue. Did I make a mistake by not fully understanding my plan? Sure. But I trusted the expertise of oral surgeons and my insurer, both of whom know way more about this than I do and whose word I should be able to trust.

You may disagree but I don't feel it's that unreasonable to decide to rely on professionals to help me understand and interpret and I am certainly going to hold them accountable for this mistake or at least ask that they can come to a reasonable compromise given the situation.
posted by tmason at 6:46 PM on September 13, 2010 [1 favorite]

Keep in mind, then, that the professionals you relied upon were not INSURANCE professionals. Sure, they deal with dental insurance regularly, but they are not lawyers, nor are they your insurance company.

It is unreasonable for you to expect the dental office to insure you against your insurance company.
posted by Rendus at 7:04 PM on September 13, 2010 [2 favorites]

Pay your dentist, decide whether or not to fight your insurance separately. Personally, I would at most write the state Attorney General and the Insurance Commissioner what you have written here, and see if they will take up the cause.
posted by zippy at 7:08 PM on September 13, 2010

It The oral surgeon's office maintains that "we were never told there was no coverage for these services"
It sounds like the dentist's office called to see what Aetna covered for the procedures, NOT whether your specific policy covered those procedures. Did the dentist's office represent to you that the conversation was about what your plan covered?
posted by misterbrandt at 7:09 PM on September 13, 2010 [2 favorites]

There can be wide variation in what is covered from one policy to the next even from the same company (especially if it is an employer sponsored plan). It is entirely possible that Aetna does have codes and standard pricing for these procedures since it is covered under some of the plans that they issue, just not yours. If the office asked for codes and prices but was not clear that they wanted a pre-certification specific to you and your policy then they may have gotten an answer to the question they asked, not the one that they intended.

I'm wondering how much difference there is between what the surgeon would get paid from Aetna (+ your $600) and the $3200 that they are billing you. I know that the negotiated price paid by insurance companies is often far lower than the standard list price. As a minimum, since they did not give you correct information, they should be willing to settle for what they would have gotten if the coverage had been in place. Since you have the numbers, you can easily see if that would make much of a difference in your case.
posted by metahawk at 7:14 PM on September 13, 2010

I went through this same crap when I had my wisdom teeth extracted. This was Cigna, and I had to bounce back and forth between the medical insurance and the dental insurance before I could get one of them to agree to pay for it. Which they did. I think it was $1000 for all 4 toofes. And the only way I could get them to actually cover it was to quote from my little book of coverages where it said which end of the company was responsible for paying for oral surgery. But I forget which it was, sadly.

I would call the number on your card and just keep pestering them. As well as get a copy of your actual explanation of benefits, and pore over it for something that looks relevant. Maybe talk to the HR people if your insurance is through an employer?

Moral of the story: call them yourself in the future; try to get something in writing/fax.

I doubt the dentist office was engaged in any game playing, but surely they can't expect you to pay up instantly until you get it all sorted out. Let it ride until you are absolutely sure you HAVE to pay. Because once you pay it, it will be harder to get the money back.
posted by gjc at 7:24 PM on September 13, 2010

Does your state have an insurance commissioner? It might be worth writing to that office. I'd include more specifics than you have here - specific wording of the letter, etc. Also, the exact wording and format (or whatever you can get) of the dental office's call record(s).
posted by amtho at 7:29 PM on September 13, 2010

Assuming you can't get your insurance to pay for anything, since you can't get blood from a stone, you might explain the whole thing to the dentist's office, explain that you don't have $3200, and see if you can settle for something less.
posted by Slinga at 7:42 PM on September 13, 2010

You might want to check to make sure whether or not your regular health insurance would cover the procedure. I think my extractions were covered by my health insurance and not my dental insurance, since it was done by an oral surgeon and not a dentist.
posted by that girl at 8:59 PM on September 13, 2010 [1 favorite]

It sounds like you have the estimate from the dentist in writing. The question, then, is who made the mistake: Aetna or the dentist? Contact your local government officials who oversee such things, let them know that you have a dentist estimate that shows the out-of-pocket and insurance coverage on which you based your decision to proceed with treatment, and now the dentist is billing you more because the coverage doesn't match their estimate, even though they did the coverage research. Then ask which of the two parties you should be pursuing, as far as the laws in your area.
posted by davejay at 9:06 PM on September 13, 2010

tmason: "The letter I have from the oral surgeon states that their office requested, from Aetna, specific codes for coverage and that they were given exact amounts that Aetna would pay them. (I have a copy of the form with these numbers on it). The oral surgeon's office maintains that "we were never told there was no coverage for these services"."

Is the form you have from your oral surgeon or is it from Aetna? If it is on Aetna letterhead or even an email from an Aetna employee then I would guess you have grounds to sue. Bring any direct evidence (not just the word of your oral surgeon) to a Lawyer or try your luck in small claims court.
posted by Bonzai at 9:44 PM on September 13, 2010

Response by poster: @Bonzai: the letter is from the oral surgeon. Aetna denies everything.

@mmisterbrandt: Yes. The oral surgeon made it clear that they called Aetna on my behalf (after taking my insurance car) to discuss my specific plan and they said "your plan covers this much, here's the difference".

@davejay: Yes, exactly. Good thinking!

Thanks, everyone. I'll use some of these ideas going forward.
posted by tmason at 3:44 AM on September 14, 2010

I am not sure if there is much that you can do now, but you might continue trying to work with your insurance company. The squeaky wheel may get the grease.

In the future, get a written pre-authorization of benefits, or something similar.

Don't screw your oral surgeon - I'm already surprised that he didn't make you pre-pay. You may be able to settle with them for a cash discount if your insurance doesn't cover it at all.
posted by iknowizbirfmark at 6:10 AM on September 14, 2010

So Aetna says they have a recording of the call with your surgeon's office, and that they did not provide numbers. But your surgeon's office says they did - and even gave you the specific numbers.

I am not a laywer, but if this was me I would sue the insurance company in small claims court, file for discovery. Either Aetna is lying or your dentist is lying. If Aetna is not lying, then sue your surgeon.
posted by An algorithmic dog at 7:28 AM on September 14, 2010

Response by poster: @iknowizbirfmark: I prepaid the $600 they told me it would cost. Why would I have prepaid $3,600 that neither of us had any indication would pop up?
posted by tmason at 12:05 PM on September 14, 2010

Seconding what others have said, namely that you may be able to negotiate the bill down to what insurance would have paid, rather than the list price for the procedure. Be polite and explain the situation if you have to, and then ask for a reduced rate. The worst that can happen is they say no.
posted by zippy at 7:53 PM on September 14, 2010

Able was I ere I saw Aetna.
posted by dott8080 at 8:14 PM on September 14, 2010

Why would I have prepaid $3,600 that neither of us had any indication would pop up?

Many oral surgeons and dentists will require you to prepay everything so that you can't not pay the bill is the insurance coverage turns out to be different than expected.
posted by iknowizbirfmark at 11:37 AM on September 15, 2010

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