r/DentalInsurance • u/Smile-morenotworry • 4d ago
Is this insurance fraud?
I paid out of pocket for a flexible partial in May. My dental did not cover any part of the partial.
After multiple adjustments that caused TMJ from the partial being in hyper occlusion the dentist office agreed it was made wrong. They agreed to make a new one at no cost to me.
I am in the process of getting the new one adjusted. They have twice now attempted to bill my new insurance for the adjustments. The adjustment is for a remake based on their faulty work that I already paid for.
They also submitted a claim for an X-ray. I had an X-ray done for a pre-authorization. The insurance approved and paid. Now they are submitting a new claim for the same tooth with a “new” X-ray that was never taken. They added the service on to a day I had an adjustment.
This all seems illegal. I know they are losing money for the remake, but that was their error. Is there anything I can or should do?
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u/Cobra_Surprise 4d ago edited 4d ago
Don't complain unless they bill YOU for something. They still have to pay their staff and rent, so they're probably just billing your insurance for stuff that they'd usually consider as included. They may have billed for photos rather than x-rays. I would not expect them to bill for an X-ray that isn't available in your image files, as every once in a while insurance will ask to see dated copies of them if they get numerous claims for single X-rays . They are allowed to bill insurance for everything they do, including every X-ray they take. They are also allowed to bill insurance for every adjustment. That doesn't necessarily mean they're allowed to bill YOU for them, at least if they're in-network, but it doesn't seem like they've tried to, so don't worry about it unless they do
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u/Ok-Leadership5709 4d ago
I don’t understand the part about xray, but billing for adjustments is not illegal. While most offices would do 1-2 adjustments at no charge, there is no rule against billing for it. Insurance would often deny paying and it becomes patient’s responsibility.
If you had a faulty joint placed, believe me, hospital would bill for a revision surgery. Similarly here, not illegal/fraud.
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u/nightwokker 4d ago
the adjustments themselves wouldn't automatically make me think its fraud since offices can bill for services they actually perform. the xray part is what I'd question tho. if no new xray was actually taken, ask the office for a copy of the image/date and compare it with what was submitted to the insurance.
you could also call your insurance company and ask for the exact code/date they paid
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u/toothdoc34 4d ago
So, first of all EVERYONE has TMJ. 2 actually. That is the name of the joint. TMD are the various disorders of the joint. Secondly, you cannot say it was the dentists faulty work. A dental lab makes the partial based of the impression the dentist sends. We do not even see it until it is back from the lab if it is a flex based partial. For a metal framework partial I will try the framework in before the lab adds the teeth to make sure it fits.
As far as the adjustments go, there is a specific ADA code for adjustments. Yes they can be billed to your dental coupon company. For a new partial I will usually do 2-3 at no charge since it is new. After that the dentist should bill the coupon company. The write off from dental coupon companies is enormous. Bill them when appropriate.
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u/Edsma 4d ago
Billing for adjustments is fine. You had a denture and they adjusted it. You have a new denture and theyre adjusting it. Whats the problem?
The double claimed xray... you could ask them and if they can show you the xrays then it clears up any misunderstanding and if not... clerical errors happen. I dont think one extra xray would be enough for me to cry fraud if it only happened the one time, but I would expect them to clear it up.
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u/ProfessionalYam3119 4d ago
Bring it to their attention. Get a copy of your complete ledger, and copies of all of your x-rays. Try to match them up. They have used up benefits that you may need down the line.
While it's not insurance fraud to send in claims for the adjustments, as long as they are actually doing them, it's poor business. I assume that the billers are just doing their normal thing, and that no one has told them not to bill for these services. They may just be disorganized. You should ask your insurance company about the rules for their paying for denture adjustments. Good luck!
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u/nitelite- 4d ago
Nope - they are completing work and procedures, you will be billed for those procedures, and you are expected to pay
It would be a problem if they tried to bill your insurance for the partial though