Action: Three years later, claim is still out

I have been receiving a bill from Pinellas Dental Specialties for an amount owed on a procedure that should have been covered by my dental insurance. I have spoken to Pinellas Dental many times regarding this, to no avail. I have also spoken to the insurance company I had at the time. The insurance company has told me that Pinellas Dental did not file within the year's time frame to do so and has refused to pay it. The items that were sent to the insurance company within the given year were paid, so it isn't a matter of not being covered.

I have received paperwork from the insurance company stating that I owe nothing to Pinellas Dental. I have paid Pinellas Dental $272.60. Of that, $100 was to keep it from going to collections, which it has anyway. The other amounts, $20.60 and $152, I paid at the time of services and was told that when the insurance paid it, I would get a refund check. The insurance has paid for those things, and I still haven't gotten anything back from Pinellas Dental. I think it owes this to me since it received the money twice, and the insurance has told it to write off the rest of the bill. Please help me finally get done with this. I have been fighting it for almost three years now. Summer Willhoite McMath

Response: Lori Davis, office manager for Pinellas Dental Specialties in Largo, said she has been been trying to process this claim for nearly three years now in an effort to help you. When you came in for your initial consultation, the estimate you signed for the procedures that were performed in May 1998 states that Pinellas Dental "will gladly file your insurance as a courtesy, and accept assignment of benefits. However, if the insurance company does not pay after the second submission, it will be your responsibility to pay Pinellas Dental Specialties for the services and resubmit for the insurance on your own."

Pinellas Dental Specialties started submitting this claim to your insurance company for processing on June 1, 1998, Davis said. Whenever the dental practice called the insurance company to inquire about the status of the claim, it was always told the claim had never been received. Each time, the claim was resubmitted. Davis said at least eight claims and duplicate X-rays were sent to the insurance company, including one set that your mother obtained from the office so she could mail it to the insurance company herself, and one time by certified mail.

The insurance company finally responded with a denial on May 5, 2000, stating that it was "no longer processing these claims." Davis said the insurance company did, however, receive the claim for your initial consultation, which it paid. Since you had already paid this charge, the insurance payment was applied to your outstanding balance.

You account was sent to the practice's attorney June 6, 2000, two years after the date of service. When you received the letter from the attorney, you called Pinellas Dental and asked that it keep trying to get the funds from your dental insurance company. Davis said she agreed to keep trying.

You also called the insurance company, which instructed you to tell Pinellas Dental to write off the bill. Davis said it is not reasonable to expect a provider to write off a legitimate charge simply because an insurance company says it should.

Davis said she feels justified in collecting for services rendered either from you or your insurance company.

With regard to the $152 you paid, which you feel Pinellas Dental owes you, Davis said that amount was the estimated amount you would owe on the entire procedure after your insurance company paid its share.

Since the problem certainly appears to lie with the insurance company, it seems reasonable that Pinellas Dental Specialties would continue to try to collect the outstanding balance of $496.34. Let us know if you would like us to pursue this with the insurance company, and we will send you a "consent to disclose information" form to sign and return.

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Action solves problems and gets answers for you. If you have a question, or your own attempts to resolve a consumer complaint have failed, write Times Action, P.O. Box 1121, St. Petersburg, FL 33731, or call your Action number, (727) 893-8171, or, outside of Pinellas, (800) 333-7505, ext. 8171, to leave a recorded request.

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