- Jurisdiction
- New York
Hi,
I need advice on how to proceed.
I had a TMJ problem. Called my dental insurance company, and they referred a TMJ specialist.
Went to that doctor. The first thing was, "we do not accept insurance", even though he is a provider.
I was in pain situation, when I agreed for out-of-pocket treatment, he let me sign statement, that "I know that my insurance won't pay for treatment.... blah", but the doctor told me that I can file a claim with my insurance myself later.
I signed, paid for everything. Work was done, no complaints there.
I filed an insurance claim myself. First time ever.
In the first claim, doctor instead of dental codes, provided medical codes. The claim was denied.
I resubmitted the claim, this time with dental codes. The form was signed by a doctor too. In that form was just one total amount for treatment. Claim was accepted.
Insurance started to ask for details, first question was "which arch" was work done. So, I resubmitted the claim again, with dental codes, doctor signed new claim form.
When insurance received it, they marked, as "received outside date range for the claim", I called insurance, explained that it was not new claim, it was additional information for the previous open claim. They moved my claim to grievance dept. Them self, not me. So, they continue to work on claim. At this point the name of the doctor was not mentioned.
Insurance rep asked me to provide cost per procedure. So, I called doctor's office, and asked for Itemized statement. The doctor refused. Then the insurance rep called doctor and asked for Itemized statement, they also refused. Because this doctor is a contractor and provider with that dental insurance, the representative was shocked and reported this doctor to her superiors. Her questions were. Why provider did not accept insurance, why he asked for out of pocket even my dental insurance plans cover it. So, "snowball start rolling" for this doctor. Then, the doctor called me, and told me close grievance against him, which I got nothing to do to begin with, or he's going to retaliate, sabotage, my claim, so I would not get anything, or bare minimum. I tried to explain to him that the insurance mention his name in that claim, only because your office (front desk) was rude to insurance rep, which you have contract with. So, the doctor submitted minimum cost for initial exam, like $42, and for x-ray $58, just in "spite". And for TMJ mouth guard, he starts submitting medical codes again, even previously he was submitted dental codes, again, just to retaliate. So, insurance denied claim for mouth guard. This from insurance letter:
"Partially overturned, D0150, D0330 are allowed, and the denial is upheld for D7880", even code D7880 is covered 60% by my PPO plan. Insurance told me, "file appeal again..." It's going to be the 4th time....
So, what's my next steps. The doctor is not cooperating, and the contrary he is sabotaging claim (once again, I paid 100% for the job and visits out of pocket) to INSURANCE PROVIDER. And insurance denying big chunk of my claim, even I have coverage. Is there any legal action there I can take?
Thank you.
I need advice on how to proceed.
I had a TMJ problem. Called my dental insurance company, and they referred a TMJ specialist.
Went to that doctor. The first thing was, "we do not accept insurance", even though he is a provider.
I was in pain situation, when I agreed for out-of-pocket treatment, he let me sign statement, that "I know that my insurance won't pay for treatment.... blah", but the doctor told me that I can file a claim with my insurance myself later.
I signed, paid for everything. Work was done, no complaints there.
I filed an insurance claim myself. First time ever.
In the first claim, doctor instead of dental codes, provided medical codes. The claim was denied.
I resubmitted the claim, this time with dental codes. The form was signed by a doctor too. In that form was just one total amount for treatment. Claim was accepted.
Insurance started to ask for details, first question was "which arch" was work done. So, I resubmitted the claim again, with dental codes, doctor signed new claim form.
When insurance received it, they marked, as "received outside date range for the claim", I called insurance, explained that it was not new claim, it was additional information for the previous open claim. They moved my claim to grievance dept. Them self, not me. So, they continue to work on claim. At this point the name of the doctor was not mentioned.
Insurance rep asked me to provide cost per procedure. So, I called doctor's office, and asked for Itemized statement. The doctor refused. Then the insurance rep called doctor and asked for Itemized statement, they also refused. Because this doctor is a contractor and provider with that dental insurance, the representative was shocked and reported this doctor to her superiors. Her questions were. Why provider did not accept insurance, why he asked for out of pocket even my dental insurance plans cover it. So, "snowball start rolling" for this doctor. Then, the doctor called me, and told me close grievance against him, which I got nothing to do to begin with, or he's going to retaliate, sabotage, my claim, so I would not get anything, or bare minimum. I tried to explain to him that the insurance mention his name in that claim, only because your office (front desk) was rude to insurance rep, which you have contract with. So, the doctor submitted minimum cost for initial exam, like $42, and for x-ray $58, just in "spite". And for TMJ mouth guard, he starts submitting medical codes again, even previously he was submitted dental codes, again, just to retaliate. So, insurance denied claim for mouth guard. This from insurance letter:
"Partially overturned, D0150, D0330 are allowed, and the denial is upheld for D7880", even code D7880 is covered 60% by my PPO plan. Insurance told me, "file appeal again..." It's going to be the 4th time....
So, what's my next steps. The doctor is not cooperating, and the contrary he is sabotaging claim (once again, I paid 100% for the job and visits out of pocket) to INSURANCE PROVIDER. And insurance denying big chunk of my claim, even I have coverage. Is there any legal action there I can take?
Thank you.
