I submitted an out-of-network claim to MetLife dental insurance and then had to fight them for ages (over a year) to reimburse me. They finally paid out…except they issued a check to the dentist, who I had already paid in full. The dentist was great and tried to sign the check over to me, but my bank wouldn't take it, so I had to fight MetLife again to send another check directly to me. They did. It is about $600 more than the check they sent to the dentist. Obviously this worked out in my favor, but I don't understand why it's a different amount.
The dentist gave me all of the paperwork that came with the check, including the patient benefits statement that says "this should not be distributed to patients or other insurance carriers" lol, so I can compare that with what the insurance sent directly to me. Would anyone be able to explain why the allowed amounts were different when everything else is exactly the same? It just feels wrong that my same insurance policy would pay one amount to me and a different amount to the dentist.
Here is what the dentist received:
| You Submitted | Allowed Amount | MetLife Paid | |
|---|---|---|---|
| $ 128.00 | $ 119.00 | 100% | |
| $ 1,700.00 | $ 1,440.00 | 50% | |
| $ 550.00 | $ 330.00 | 50% | |
| $ 1,300.00 | $ 425.00 | 80% | |
| $ 79.00 | $ – | ||
| Total: | $ 3,757.00 | $ 2,314.00 |
Here is what I received:
| Your Dentist Submitted | Allowed Amount | MetLife Paid | |
|---|---|---|---|
| $ 128.00 | $ 119.00 | 100% | |
| $ 1,700.00 | $ 1,549.00 | 50% | |
| $ 550.00 | $ 377.00 | 50% | |
| $ 1,300.00 | $ 1,108.00 | 80% | |
| $ 79.00 | $ – | ||
| Total: | $ 3,757.00 | $ 3,153.00 |
Why did MetLife reimburse my claim at two totally different amounts?
byu/Lemondrop619 inInsurance
Posted by Lemondrop619