Complaints

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• Initial Complaint

  Date:06/04/2024

  Type:Billing Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  I'm reaching out because Paul DiFranco Orthodontics failed to file my insurance claims correctly since I started the treatment in 2023. The total treatment cost is $4,308 and the amount expected from the insurance was $2,000. The monthly payment from the insurance expected from the insurance I had in 2023 (prior to me switching the insurance in 2024) was 50% of the total cost of treatment with a maximum amount of $2,000/12= ****** The amount the dentist shouldve received until 12/31/2023 (end date of the initial insurance) is: May 23: $****** June 23: $****** July 23: ****** August 23: $****** September 23: $****** October 23: $****** November 23: $****** December 23: $****** Total is $1,333.33 The remaining balance is ($2.000-$1,333.33=$666.66)The dentist's office was mistakenly filing the claims for the amount of $92 as the total cost of monthly treatment instead of $359 ($4,308/12). The insurance paid 50% of the amount filed in the claims which is $92/2 = $46. When asked to clarify the numbers in the claims, The dentist's office representatives did not provide any explanations and they mentioned that filing the claims is a courtesy and they have no responsibility regarding that. The dentist's office, started threatening to send the remaining balance to the collection services without trying to explain the numbers I'm asked to pay. I have attached the contract, the claims documents and a screenshot showing how the monthly calculation was incorrect showing $2,000 as the total amount expected and a monthly amount of $92 which is incorrect since $2,000/12 equals $166. I believe the office is liable and responsible to pay the delta amount caused by filing the insurance claims incorrectly. I offered to pay half of the delta as a resolution but continued to stonewall and further escalate by sending a payment while there is an ongoing dispute. Looking forward to hearing from you and getting your assistance.

  Business Response

  Date: 06/05/2024

  This is an unfortunate matter. **** changed his insurance mid way through treatment from a PPO to a HMO. He was notified right away when the insurance sent us a copy of the explanation on benefits showing they will not be paying the full amount. When our office spoke to his insurance company, the rep advised us to have **** call and they would gladly explain his benefits to him. Also his insurance verified all things were done correctly on our end. He was advised this information and has not called his insurance to get an explanation of his benefits. We have a signed contract with the patient. On the contract, it states, "Insurance is an estimate of benefits only. We bill your insurance carrier as a courtesy. If for any reason your insurance carrier does not pay the full estimated benefit, the remaining portion will become the guarantor's responsibility, as the obligation to pay for treatment is always your responsibility.". ****'s initials are next to that line on contract as well as a signature on the contract. He has sent multiple threats via email saying he was going to the Attorney General with this matter and was going to *** our practice. He has now stopped his monthly payment and there is still a balance he is responsible for. Hopefully this is*** can be resolved. Please let us know what else you need from us. We want to be careful due to any HIPPA laws. We'd be happy to speak to you regarding this matter. We do have backup documentation for everything.

   

  Thank you

  Customer Answer

  Date: 06/06/2024

   
  Complaint: 21795888
  
  I am rejecting this response because:

  *$2,000 divided by 12 does not equal $92!* (please look at the claims document)
  Unfortunately, Paul DiFranco Orthodontics practices response continues to be misleading and deceiving by creating a narrative that the issue is due to me changing the insurance. My escalation is regarding the claims filed prior to 1/1/2024.
  I have explained that Im fully responsible for the unpaid insurance balance in 2024 which is as follow:
  January: $166,67 ($2,000 total expected amount/12)
  February: $166,67
  March: $166,67
  April: $166,67
  Total: $666,67
  The practice response clearly avoids explaining the numbers in the claims. In fact, there are no numbers in the response overall.
  I have provided the facts and backed them up with the documentation and the numbers explaining what was expected and highlighting the errors.  
  The practice mentioned that their claims were filed correctly per their conversation with the insurance (allegedly) but they have not explained how they came up with the number $92 which was the basis of the 50% insurance benefit payment.
  I was gaslighted when I asked about the numbers and the details behind the balance Im asked to pay, and I mentioned the legal route when I was threatened by the collection services (see screenshot).
  I have completed the payment of the amount which is not covered by the insurance ($2,308) through monthly payments as stated in the agreement.
  I requested not to move forward with any additional payments since the remaining balance is under dispute, but the practice went ahead and took the money from my bank account without my consent.
  I also tried to resolve the issue (see attached email)amicably by offering to pay an additional $300 (half of the delta amount) for a total balance amount of $966 even though the delta amount is caused by the office errors.
  Im hoping that you step in and look at the facts and the numbers to resolve this issue since Paul DiFranco Orthodontics practice does not want to take any responsibility nor be held accountable.
  Your help on this is greatly appreciated. 

  
  Sincerely,
  
  *******************

  Business Response

  Date: 06/10/2024

  Attached is a signed contract with *********************** signature. Within the contract we have it broken down to explain insurance. We advised **** to call the insurance company so they can explain further how it all works. In addition the patient changed his insurance policy as of January 2024 which in turn changed his orthodontic coverage. We have many conversations and many emails regarding this with no solution as the patient refuses to contact his insurance company regarding this manner. He insists we did not file the insurance properly. If he fully understood his benefits and how orthodontic benefits are paid out he would know we did our part correctly. Despite all the back and forth along with a signed copy of his contract he refuses to pay his bill. I hope all this is helpful in closing this complaint. If anything else is needed please advise.

  Customer Answer

  Date: 06/11/2024

   
  Complaint: 21795888
  
  I am rejecting this response because:
  *$2,000 divided by 12 does not equal $92! *
  Unfortunately, Paul DiFranco Orthodontics practices response continues to be misleading. I was hoping to see a clear response and explanation regarding the numbers in the 2023 claims. I believe there is only one way to calculate the monthly payment which is the total amount/12 (in this case $2,000/12 = $166,67) unless the practice has a different formula that we dont know about and or we are missing something.
  I have a clear understanding of my dental benefits in 2023.I have had a similar insurance in the past and I had no issues with claims filed utilizing the same benefits. My benefits are 50% with an annual maximum of $2,000 (which applies in this treatment).
  Paul DiFranco Orthodontics practices response claims that I have not reached out to my insurance which is not true. I have reached out to ****** the company who is managing my benefits and my insurance on March 20, 2024, and the call lasted 24 minutes (Please see attached screenshot) where they explained my benefits and asked me to reach out to the practice for more details about how much was paid which led me to uncover errors in the claims.
  The practice office is trying to deflect the conversation about the main issue by pointing the finger by claiming I refused to pay my bills while I have already paid the 12 payments in the agreement with a total of $2,308. I also offered to pay an additional $966 to resolve this issue but Paul DiFranco Orthodontics refuses any solution. The practices response continues to be combative and refuses to explain the numbers, take responsibility for the errors and be held accountable.
   Please, look at the numbers and the facts and feel free to have any subject matter experts look at the claims and provide their opinion about this case.
  As always, your help on this is greatly appreciated. 
  Sincerely,
  
  *******************