Complaints

• Initial Complaint

  11/07/2023

  Complaint Type:

  Order Issues

  Status:

  Answered

  More info

  Hello - We used this provider ("Figueroa") to provide orthodontics for our daughter, *****. Figueroa provided her braces in January 2022, and removed her braces in September 2022. Recently, more than a year later, in November 2023, we received a notification that Figueroa would like us to pay $750 additional toward her braces because Figueroa failed to timely bill our insurance company (Delta Dental). Figueroa contends that it did not bill our insurance company until at least January 2023, months after it provided the services, and claims that the insurer denied the claim because our coverage did not extend into 2023, even though the services were performed in 2022. In short, Figueroa failed to timely bill our insurer, failed to make clear to the insurer that it performed the services in 2022, and wants to pass off its negligence onto us. Meanwhile, the insurer will not accept our grievance because it considers only grievances lodged within 180 days, and Figueroa failed to tell us about the issue until November 2023, more than a year after the services, and several months after the issue arose.

  Business response

  11/17/2023

  ******************************* coordinator had an extensive conversation by phone and email with ************** on November 11, 2023, to better explain the situation at hand.
  
  In 2022 we provided a treatment plan for the ***** family as well as financials that included an estimate of what their insurance will cover based on the correspondence we received from their Delta Dental policy. The family signed the contract which states that the insurance coverage is an estimated amount and any unpaid balances from insurance would be the familys responsibility.
  
   We submitted the initial claim on the day the patient started treatment 1/10/22  and received an initial insurance payment.  The Delta Dental policy states under the orthodontic payment, that following the initial claim payment the remaining orthodontic benefit will be paid after 12 months, provided there has been no lapse in coverage. Unfortunately, the policy was changed and the orthodontic benefits were dropped before the second half was paid out and we were not informed of this change.  When we submitted the claim for the 2nd installment, as we did not receive the anticipated payment automatically at the 12-month mark,  we never received an explanation of benefits stating that the policy had changed and there was no longer any orthodontic coverage. We had been in contact with Delta Dental regarding this claim and at no point did any of the representatives state that there was no longer orthodontic coverage. It was not until October 27, 2023, that we were informed of this information. We still attempted to reprocess and appeal this for payment on behalf of the family. Our first correspondence with the ***** family was on 10/30/23 regarding this matter as we had only been made aware a few days earlier the payment would not be forthcoming.
  
   We have offered the family payment plan options as well as having a conference with the insurance company to ensure everyone has the same information. We have continued to work with the Rileys and Delta Dental on the insurance appeal. 
  
  
  A copy of claims, EOBs, and contracts can be provided if a HIPPA release is provided for our records.
  
  

  Customer response

  12/05/2023

   
  Complaint: 20833509
  
  I am rejecting this response because:
  My contract for orthodontics with Figueroa Orthodontics clearly states that my daughter's treatment would be for "6-8 months."  Ultimately, it ended up being approximately a month longer, but, regardless, all of the services were clearly provided in 2022.  Figueroa put her braces on in January and took them off in September 2022.  I had insurance coverage for orthodontia in 2022 for this purpose.  Despite the fact that my contract for my daughter's orthodontia indicated a 6-8 month period AND she got her braces off by September 2022, Figueroa's failure to bill for the services until January 2023 is inexcusable.  At no point prior to the end of October 2023, did anyone from Figueroa inform me that Figueroa had waited until 2023 to bill for the services provided in 2022.  Figueroa now has threatened to charge me for services that were clearly covered by my insurance, had Figueroa followed reasonable business practices. 
  Sincerely,
  
  *************************

  Business response

  12/18/2023

  After another reprocess of the claim Delta Dental of IL has now paid the remaining balance on this contract. 

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