Personalized Dental Care

Dear Mrs. [redacted]
We are in receipt of your complaint from August 1.4, 201.4. This E-mail serves to notify you of
our position at MK Personalized Dental Care, in regards to your concerns.
We regret and feel deeply sad for your experience in our office lately,...

more so since the
surgical treatment of your son [redacted], was a total success. The billing department of your
dental insurance ([redacted]) is, in our opinion, sub standard, deceiving and
uncooperative. We are a group of dedicated medical and dental professionals, who performed
the procedures on your son, at the highest caliber of competence, and the insurance company
are trying to avoid responsibility, under your contract, on obscure and ridiculous tactics. This is
in essence the core of your complaint.
We are not careless and we do not lack of diligence. We called your insurance on
several occasions to verify coverage and dental plan details. A pre-authorization, is not
mandatory when the eligibility is established and also a pre-authorization is not a guaranty for
payment (you can find this phrase on any dental or medical pre-authorization forms). We
perform this procedures for all our patients and we do not have this kind of responses from
other insurance companies. [redacted] and yourself, had treatment done in the past, for larger
amounts then $300 (01..21..201.3 for$ 1.,041..00 and 05.02.201.3 for$ 763.00) and we had
no need for pre-authorizations or difficulties in collecting from your Insurance. [redacted] Blue
Cross recently is finding new excuses to delay or deny payments to providers like us,
In general.
We contacted the [redacted] we made a request for
assistance and applied for independent medical review. We will continue to resolve this
dispute with the insurance company. Mrs. [redacted] at this point, we would like to reassure you,
that we do not intend to force collection on your account.
We hope that this note will help you understand our position better and we also promise to
keep you posted on any progress we make.
Very truly yours,
[redacted]
[redacted]
Drs.MONTGOMERY & KIRIAK, Ape.
Phone: [redacted]

Review: I have copied the letter that I have sent to Personalized Dental Care which explains the nature of the complaint.This letter serves to notify your office of potential legal action against you in regard to the services rendered on the above date of service.On January 21, 2014, I took my son [redacted] to your office for a routine check-up. During the visit, x-rays were taken and it was noted that [redacted]s molars need to be removed. After the check-up my son [redacted] and I met with Ms. [redacted] to discuss the cost of having his teeth extracted.During the discussion, I made it very clear that I would not be able to afford the procedure if it was not covered by my dental insurance[redacted] Ms. [redacted] contacted [redacted] to discuss the coverage for the procedure. When the call was completed Ms. [redacted] advised and assured me that 80% ($2,380.00) would be covered by my dental insurance and I would be responsible for 20% ($690.00). I advised Ms. [redacted] that I would need to discuss the cost with my husband before proceeding with the dental services. That evening, I discussed the dental visit findings and the cost of the services with my husband. After reviewing our personal finances we determined that we would be able to afford the 20% ($690.00) and we decided to proceed with the extraction of the molars. On the date of service I paid the 20% portion that I was responsible for the services.When I learned that claim submitted to [redacted] was denied and I was responsible for the full amount of the bill, I contacted the dental office and spoke with Ms. [redacted]. I explained to her thatI agreed to proceed with the services based on her coverage inquiry with Anthem, indicating I would only be responsible for 20% of the services. I also explained that we would never have gone through with the services, had I known this was going to happen. Ms. [redacted] did not appear to be concerned with what I had to say. Her only recourse was that, she could place me on a payment plan. Her response was not acceptable to me and showed a lack of sensitivity, as I had gone to great length in explaining my financial situation to her.As a result of my discussion with Ms. [redacted] I contacted [redacted] and spoke with Representative. Ms. [redacted] confirmed that Ms. [redacted] did contact them to confirm coverage on January 21, 2014. Ms. [redacted] also stated, that they always inform dental offices that if the cost exceeds more than $300, dental offices need to submit a preauthorization request. She also stated they do not authorize services over the phone.In my research, I found that prior to rendering extensive dental services; it is standard practice for dental offices to submit supporting documentation (pre-authorization) in order to establish the necessity of the services to be performed. Once the insurance company reviews the request, they reply with an approval or denial. The patient now has the option to decide whether to incur the cost or not.In this case, it is my contention Ms. [redacted] did not follow protocol by submitting a preauthorization request. Ms. [redacted] led me to believe that I would only be responsible for 20% of the charges which is what my policy states. I made a decision to proceed with the dental services based on what I believed was expert information given to me by Ms. [redacted]. Not being an expert on these matters, I relied on her expertize to make an informed decision of whether or not to move forward with the procedure. My reliance on her expertize has now become a detriment and your office is now requesting payment in full.Had Ms. [redacted] followed the proper protocol by submitting a pre-authorization request, I would have made a decision based on that outcome and I would be responsible for that decision. I would not be suffering in a financial hardship because I was given incorrect information.For the reasons mentioned above, Im requesting that your office waived the cost of the services rendered totaling $1,690.00. I look forward to a positive outcome. If I do not receive a response by close of business on August 29, 2014, I will pursue other legal remedies available to me and include other patients who may have been impacted by the carelessness and lack of diligence of your office.Desired Settlement: Im requesting that Personalized Dental Care waive the cost of the services rendered totaling $1,690.00.

Business

Response:

Dear Mrs. [redacted]

We are in receipt of your complaint from August 1.4, 201.4. This E-mail serves to notify you of

our position at MK Personalized Dental Care, in regards to your concerns.

We regret and feel deeply sad for your experience in our office lately, more so since the

surgical treatment of your son [redacted], was a total success. The billing department of your

dental insurance ([redacted]) is, in our opinion, sub standard, deceiving and

uncooperative. We are a group of dedicated medical and dental professionals, who performed

the procedures on your son, at the highest caliber of competence, and the insurance company

are trying to avoid responsibility, under your contract, on obscure and ridiculous tactics. This is

in essence the core of your complaint.

We are not careless and we do not lack of diligence. We called your insurance on

several occasions to verify coverage and dental plan details. A pre-authorization, is not

mandatory when the eligibility is established and also a pre-authorization is not a guaranty for

payment (you can find this phrase on any dental or medical pre-authorization forms). We

perform this procedures for all our patients and we do not have this kind of responses from

other insurance companies. [redacted] and yourself, had treatment done in the past, for larger

amounts then $300 (01..21..201.3 for$ 1.,041..00 and 05.02.201.3 for$ 763.00) and we had

no need for pre-authorizations or difficulties in collecting from your Insurance. [redacted] Blue

Cross recently is finding new excuses to delay or deny payments to providers like us,

In general.

We contacted the [redacted] we made a request for

assistance and applied for independent medical review. We will continue to resolve this

dispute with the insurance company. Mrs. [redacted] at this point, we would like to reassure you,

that we do not intend to force collection on your account.

We hope that this note will help you understand our position better and we also promise to

keep you posted on any progress we make.

Very truly yours,

Drs.MONTGOMERY & KIRIAK, Ape.

Phone: [redacted]