HELP , United Health Care is trying to rip me off

Posted on 2009-12-18
Last Modified: 2012-05-08
I am having an issue where I could get screwed out of  $5000 or so , My wife has TMJ and we went to a dentist to get it fixed , foolishly I agreed to pay them upfront and collect the $ from United Health Care , BIG MISTAKE , after over a year of back and forth about paperwork ect. They claim that the fair and reasonable and customary price for this procedure is $480 , so I am potentially screwed out of $4500. the only thing I can think of doing is to file an appeal . Does anyone know a better Idea? I was thinking about getting written estimates from other dentists for the same procedure and using that in the appeal . any advice would be greatly appreciated . I would also like any one reading this not to make the same stupid mistake I made.

Question by:kaos_theory
    LVL 18

    Expert Comment

    No.  Don't pay in advance.  I have UnitedHealthCare
    LVL 16

    Expert Comment

    So... IANAL, but I think getting written quotes is a good idea.

    You probably have to sue them to get anything though.  And that could end up costing you more than you save.

    Never pay in advance.  In fact, don't pay after the fact until your insurer has responded either.
    LVL 4

    Expert Comment

    Kaos Theory,

    From what I hear this is a very common thing for Dentists to do now. Your dentisit is simply out for money and there is no sense in filing an appeal with the insurace company as they WILL NOT budge. I'm sure you are aware that insurance companies have set prices for procedures that are written in contract. If you are presneted with this scenario in the future I would recommend calling your insurance company BEFORE the procedure and determine what they cover or get a second opinion before dropping $5,000 bucks as urgent as the matter seems.

    Good Luck!
    LVL 17

    Expert Comment

    Technically, the doctor's offices bill the insurance as a courtesy--they are not required to do so. And now you know why! It's a giant pain in the butt.

    In addition to filing an appeal, talk to the dentist's office and see if they will refund the difference, or part of it. It also may be worth your while to talk to a lawyer, in some cases insurance companies have negotiated contracts with companies and the companies are not allowed to charge more than that.
    LVL 62

    Expert Comment

    by:☠ MASQ ☠
    Interesting that the title to this is UHC are trying to rip you off.
    UHC publish their tariffs for TMJ and craniomandibular pain syndrome (CPS) - there are two scales one for physiotherapy and one for surgery.
    Treatment with splints, exercises, ultrasound or adjustment of the teeth attracts the lower of the tariffs while surgery is the higher.
    Your dentist will know in advance of the treatment what fee UHC will offer.

    I don't think the gripe is necessarily with the insurers here.
    Their PPO Plan specifically excludes both TMJ and CPS treatments without getting approval from UHC first
    LVL 32

    Accepted Solution

    >I don't think the gripe is necessarily with the insurers here.

    Hard fact.  It is not desirable to front the money for things that should be covered.

    I've been private-pay in the pase because a particular family dentist did not accept my work insurance.  The cash-pay amount is always lower.  Significantly lower.

    The cat-and-mouse game that the insurers and providers play forces billing to be increase XX%, because the folks authorizing payment look good when they force YY% discounts.  They know the game is there, and they still play it.

    For a dentist to ask for cash payment upfront, then tell you to ask for reimbursement, smells to me like a rip off.  If the dentist is so sure that you're covered, he shouldn't have any problems doing the paperwork himself.

    Methinks you were ripped off by the dentist...not the insurer.

    If an AutoClub tow driver asked for cash up front, and told you to get reimbursed by AAA, would you take the tow?  I'd get back in the car, lock the doors, and call AAA.

    I'm sorry the dentist ripped you off.  A phone call from their office to the insurer tells them what is covered.  It could be that they called, found that you weren't covered, and decided to milk you.

    I see no reason why a legitimate dentist would do that to you.
    LVL 9

    Expert Comment

    The primary reason that a Dentist would not deal with insurance companies would be that they have had problems dealing with insurance companies in the past.  Insurance companies want providers to work with them, it makes their insurance plans more competitive in the marketplace.  So if you have a provider who is not able to work with insurance companies there is a very good chance that they either charge substantially more than the prevailing rate, or they do substandard work that requires rework more often than the other providers in the area.   You need to do the legwork and verify if that is actually what other providers in the area charge, if not then work with the department of insurance to help you solve the problem, but don't go to the doi without all kinds of data and facts to buttress your argument.
    LVL 2

    Author Comment

    what i am thinking is first get all kinds of estimates for the treatment as evidence ,

    is there some kind of assosiation that could give guidlines as price?
    LVL 62

    Expert Comment

    by:☠ MASQ ☠

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