Paso Robles Endodontics

Review: This dentist fradulently represented to me and to United HealthCare(UHC)that they are an "in-network" dentist with UHC, then made my wife overpay them on 10/17/2013, for my root canal while I was sedated there and unable to communicate. The overpayment, at that time, was $269.50 more than the UHC allows. The dentist correctly complied with charging for services done on 10/15/2013 but inconsistently & unfairly over-billed for his services done on 10/17/2013. They inconsistently declared they were "in-network" in Oct. 2013, when I had the root canal done, but denied being "in-network" in December 2013.In December 2013, they sent me a bill for an additional $299.50, instead of a refund of $269.50. The dentist then later declared they are not "in-network." After filing a "grievance" claim with UHC, UHC recommended that I file this matter with the Revdex.com and California Dental Assn.I have made numerous inquiries and attempted to resolve this matter with the dentist, but they remain unreasonable and unyielding. I have copies of all my documentation, filed complaints and logs, regarding matter and would like to explain this to you in detail.Thank You.Desired Settlement: Stop this fraud against other patients, require this dentist to refund the $269.50 overpayment to me, dismiss all outstanding balances and also refund $196.70 of overpayment back to my dental insurance carrier, UHC.

Consumer

Response:

Review: 10060618

I am rejecting this response because:

I am rejecting the response because: Her response contains false statements, misleading information and misrepresents the facts of what occurred. It appears that I am a victim of a clever bait and switch scheme. PRE agreed, in October 2013, to charge according to my insurance plan allowances then changed the charges, for work done on October 17, 2013, in December 2013. I have attempted to resolve this with PRE on six occasions, but to no avail.

Following is my response, somewhat in the order that PRE responded to you.

The insurance company, United Health Care Advantage Medicare Complete Secure Horizon(HMO) dental plan(UHC), was led to believe that PRE was “in network” and directed me to PRE for this root canal. The PRE billing system does not appear to be in question. The breakdown of charges is clear; the amount of charges and overcharges are not in accordance to PRE's representation to me on October 14 and 15, 2013.

On 10/14/2013, I called PRE, read off the UHC insurance card information to [redacted]. She confirmed that PRE is an “in­network” endodontic dentist for my dental plan. She said that the entire root canal would be done in a single visit and scheduled a single visit for the work to be done on 10/15/2013.

On 10/15/2013, prior to beginning my appointment, she copied my insurance card and reassured me that PRE is an “in­network” dentist for my UHC plan. After Dr. [redacted]l examined my mouth and took x­rays, he decided to have me come back later, with a driver, and gave me a prescription for a sedative (Triazolam). [redacted] handed me a “Proposed Treatment Plan” estimate.I explained that the amount shown on the treatment plan estimate appears to be much more than UHC will allow for the root canal. She said that she uses only one list for estimating coding prices for all their various insurance estimate codes for patients. She explained this is only an estimate, that the actual procedures and cost can't be determined until after the work is completed and UHC determines the amounts to allow to be charged and reimbursements. She explained that UHC will cover at least 80% of the consultation and x­rays and half the root canal allowance; I will pay the other half of the allowance. [redacted] scheduled me to return for the root canal, on10/17/2013, and inquired who would be my driver.

Comparing PRE's “table” of charges and services with UHC's “Explanation of Reimbursement”(EOR) dated 10/28/2013, PRE shows they complied with UHC's allowances for the consultation and pictures(x­rays) done on 10/15/2013, totaling $116 ($75+$26 for UHC+$15Copay). However, comparing that “table” of charges and services with UHC's EOR dated 11/08/2013, shows that PRE decided not to comply with UHC's allowances for the root canal(RCT), buildup and obstruction done on 10/17/2013, totaling $739 ($560+$68+$111) and, later on, chose to charge $1308 ($965+162+181) My total copay to PRE was supposed to be: $15 plus half the allowed $739 ($15+369.50), equaling a total of $384.50.

On 10/17/2013, immediately following the root canal and while I was still under sedation, PRE demanded that my wife pay them $654 in order to release me from their office. This clearly represents an overpayment of 269.50 ($654­$384.50 copay=$269.50).

On 11/18/2013, I called PRE. [redacted] said they had not yet received any response from UHC regarding the allowed amounts. I explained that UHC related to me that my obligation for all of the work was only $384.50, not the $654 they took from my wife, and that I want them to promptly refund the $269.50 of excess payment. She assured me that they will revise and adjust the charges, according to UHC's allowances, when they receive UHC's response and payment.

On 11/26/2013, I called PRE, explained to the receptionist that UHC had paid them in full

according to contract allowances and that I want the $269.50 overpayment refunded to me, now. PRE did not return or respond to my call.

On 12/9/2013, I received for the first time, a billing statement dated 12/4/2013 from PRE (much to

my surprise) for an additional $299.50 instead of showing a refund of $269.50. I called PRE and

told [redacted] I was shocked to receive a billing statement from them for an additional $299.50 instead

of a $269.50 refund. [redacted] said she had called UHC for a “fresh” copy of PRE's contract with UHC and that she needed the fresh copy before she could revise the account billing to issue me a refund. At this point, I realized the disparity has now increased from $269.50 by an additional $299.50, totaling$569 of overcharge.

On12/26/2013, [redacted] told me that she cannot locate a copy of the signed contract with UHC; hence, PRE will not recognize the allowances as agreed in October and November 2013 and wants me to pay the additional $299.50. I reminded her that I had questioned her about the “Proposed Treatment Plan” estimate before I signed on 10/15/2013 and she had assured me PRE will adjust the charges according to UHC's “in­network” allowances and reimbursements. At this point, [redacted] denied that she told me that. She became angry and said that I was trying to get the root canal work done for free. Her responses became inconsistent. Her statements were false.

On 12/28/2013, I received for the first time, an “account history report”dated 12/26/2013, detailing

the amounts PRE decided to charge; ignoring their October 2013 concurrence to charge according

to UHC's allowances.

[redacted] is no authority on the effects of Triazolam as a sedative. I was unable to recall any communication with the dental staff or with my wife until being placed in our car at the conclusion of the root canal on 10/17/2013. In fact, Dr. [redacted]l called me later, on 10/17/2013, to ask how I was feeling and also asked if I could recall any of the procedure while I was sedated. I told him that I remembered nothing from 20 minutes after taking the two pills until he was helping my wife place me into the car, after the root canal, to leave. He indicated that this was good and usual. If I had been able to communicate, I would have not allowed my wife to pay $654 at that time (10/17/2013). Yes, I was alert and intact on 10/15/2013, when [redacted] handed me a “Proposed Treatment Plan” estimate, explaining that the actual treatment may differ depending on what occurs during the procedure on 10/17/2013. I was not cognitive or alert on 10/17/2013, when they made my wife pay $654.

I sought to resolve this matter with PRE, by phone, on 11/18/2013, 11/26/2013, 12/9/2013 & 12/26/2013 and, in writing, on 2/15/2014 and 5/6/2014. I complained to UHC regarding this issue and they called me, in January 2014, to say they couldn't find a signed copy of their contract with PRE and weren't going to take action against PRE. Instead, it appears UHC sent PRE an additional payment of $196.70 on the overcharge ($196.70 happens to be the amount of unused maximum total that UHC would pay on my behalf for calendar year 2013). The $196.70 payment reduced PRE's outstanding balance from $299.50 to

$102.80, as reflected in a Jan.21,2014 billing statement received from PRE. I think the amount of

money involved is too small for UHC to bother with.

On 2/15/2014, I hand wrote a message on PRE's billing statement dated 2/3/2014, trying to resolve

this. PRE's subsequent March and April statements disregarded my message. Sensing that it was possible that [redacted] had not made Dr. [redacted]l aware of this, on 5/6/2014, I sent a letter addressed to Dr. [redacted]l at PRE, laying out a brief description of the issue and how to resolve this. As of today, I have not received a reply.

I will be pleased to discuss and clarify the information, billing statements, declared allowances etc. with you to bear out the logic and accuracy of my claim.

Thank you for your attention to this matter.

Regards,