Dental Billing Insurance for 3 times the amount for a crown than quoted to the patient, Legal or not?
<p>The patient is given a quote for a crown total of $900.00.<br>
The patient paid the deductible and her quoted portion of $450.00 up front.  When the patient received an EOB from the insurance $1600.00 had been charged to the insurance for the same crown. When questioning the amount, the office manager stated that he can charge any amount he wants to the insurance company.  The doctor stated that the billing is out of her hands.  The insurance company states that the patient should not have gone out of network and it is out of their hands. IS THIS LEGAL?  OR THIS INSURANCE FRAUD?
Not only was the bill to insurance excessive but it also used up $700.00 more of the patients yearly maximum than originally quoted which means she will not be able to complete other dental treatment needed.  </p>

<p>Dental "quotes" are typically estimates of a patient's financial responsibility, given the insurance information provided by the patient. If you patronize an in-network practicioner, it is fairly easy for them to be pretty accurate in that estimate, but there can be some small errors when it turns out the insurance company thinks one thing and the doctor thinks something else (the doctor generally loses). This is because an in-network provider has a contract with the insurance company that says what they can charge and what they will receive. They could charge the patient more than the maximum allowed by the insurance company, but that would be a violation of their contract with the insurance company. It is very common that a doctor bills for a large sum, accepts much less than that and passes on a specific amount to the patient as their responsibility.</p>

<p>An out-of-network provider doesn't have those limits on what they can charge, also they may be less accurate in estimating patient responsibility. Indeed, an out-of-network provider could simply hand the patient a bill and a receipt, leaving it to the patient to get reimbursed, especially if the insurance company is a known pain in the neck. Insurance companies encourage you to patronize in-network by (1) limiting what the doctor can charge, (2) paying a greater portion of the bill, (3) having separate in-network vs. out-of-network yearly maxima plus often higher out-of-network maxima.</p>

<p>The doctor can <em>charge</em> any amount he wants to the insurance company, in any event – the insurance company is responsible for deciding what they will pay (a doctor can symbolically overcharge and accept lower levels of payment, if he wants to). So, yes, this is all legal. It's all part of general contract law, regarding the three contratual relations you+insurance, you+doctor and doctor+insurance.</p>

fraud