Christine Taxin
Many clinicians have the same question: Should I accept medical insurance at my dental practice? The answer is simple—absolutely. While clinical dental practices may be wary of launching their teams into the throws of the medical insurance storm, it can pay off in dividends. The learning curve can be steep, so knowing the basics, as well as where to go for help, is where every office needs to begin.
There are some key differences between medical and dental insurance. Medical plans are a traditional form of insurance, as policyholders contribute monthly premiums. These premiums are used to pay for both routine checkups and statistically unlikely events like catastrophic medical expenses. It is a safety net that pays large amounts of money when needed, and the amount a policyholder needs to pay in the form of deductibles and co-pays is relatively small in comparison.
Dental insurance is an employer or personal benefit that a person buys for his or herself. It is not designed to pay for statistically unlikely events. Rather, it is made to help policyholders offset the cost of their dental expenses. Therefore, most dental insurance plans have yearly caps on what they will pay, usually about $1,000 or $2,000 a year. This means that most patients must be judicious when they spend their dental dollars.
For many patients, especially those with severe dental issues, the amount allotted by their dental insurance will not be enough to cover the procedures needed in a given year. Accepting medical insurance may make it possible for these patients to get the dental treatments they need if the circumstances of their conditions fall under the medical billing codes for dental procedures.
There are four medical billing code categories for dental procedures. Depending on an individual patient’s circumstances, dental offices may be able to bill a medical insurance policy using these codes if the dental policy either does not cover the procedure or covers too little of the overall cost. The four code categories are detailed below.
Any diagnostic procedures that are medically necessary to determine a cause of pain—whether an infection or some other dental disease is present or the patient has congenital dental deformities—can usually be billed to medical insurance as medically necessary procedures.
Tooth extractions due to injuries or underlying diseases can be billed using medical codes if a practice accepts medical insurance. Additionally, biopsies and excisions of hard and soft tissues in the mouth are usually done for medical reasons and thus can be billed under surgical codes on medical insurance. Implant and other surgeries involving hard or soft mouth tissues are also medically billable. The only surgeries that are not billable under medical insurance are cosmetic procedures.
Treatment for abscesses and infections can be billed under this medical coding group. Tooth restoration treatment for people with eating disorders can also be billed this way. And, while most dental policies will not cover them, appliances for TMJs, sleep apnea, and tooth grinding are considered medically necessary and can be billed through medical insurance plans.
When teeth and surrounding tissue are injured in any kind of accident, it is usually considered a medical issue and billed as such. This billing code can also cover tooth restoration, implant placement, and tissue repair.
If there is confusion regarding whether a procedure can be covered by medical insurance, consider the following questions:
• Is surgery required?
• Is there an injury?
• Does a medical condition need to be diagnosed?
• Are the patient’s teeth, soft or hard mouth tissues, or jaw working improperly to the impairment of normal function?
• Is there an infection?
• Is there inflammation?
If the answer to any of these questions is yes, then the procedure can usually be billed under medical.
When a practice begins accepting medical insurance, it must cross-code medical and dental procedures to bill patients and insurance companies properly. Office staff will use codes found in Current Procedural Terminology, as well as the latest edition of International Classification of Disease. There are also comprehensive resources available that can augment training. Clinicians planning to pursue medical billing for dental procedures should be sure they have all the resources necessary to see successful reimbursement.
To ensure that appropriate billing codes are selected, all procedures, medicines, diagnostics, and services must be carefully analyzed. In complex cases, some codes may be purely dental and be billed to the patient’s dental policy, while others can be deemed medically necessary and sent to the patient’s health insurance. Calling the health insurance company ahead of time for a list of benefits the policy will cover can be very useful in selecting the correct codes and billing the correct insurance. When billing something through health insurance, the most important element is to let the insurance company know why and how the procedure will affect the patient’s overall health and wellbeing.
The process can seem complicated at first, and often teams feel that the hassle of learning how to cross-code is not worth the benefits. However, with the proper training, any team can learn the basics and start saving their patients significant amounts of money.
Even though training staff to use a new coding system can be time consuming, becoming an office that accepts both medical and dental insurance offers a wealth of benefits for the clinician, as well as his or her staff and patients. Accepting medical insurance allows offices to adequately serve most, or even all, of their patients. Additionally, the expanded options can increase an office’s client base.
Further, most dental insurance policies recommend that dental offices bill to medical for extractions, TMJ treatment, CT scans, sleep apnea treatment, and patients who need collaborative treatment between a dentist and medical doctor for a dental-related issue.
Another factor to consider is that not every employer offers employees dental insurance. However, many employers do offer some kind of medical insurance. By coding common and health-threatening dental issues through medical insurance, dentists can help patients who otherwise would be unable to afford treatment.
Accepting medical insurance can also have a significant positive impact on patients’ lives. Making checkups and procedures more affordable will allow these patients to seek regular dental care and ensure that any potential issues are caught early.
While the task may seem daunting, offices that start learning the ropes now will be ahead of the game when, as some industry experts foresee, all dental practices will be required to cross-code to stay in business. As medical benefits are required by law for everyone under the age of 19, and more and more companies are purchasing embedded plans with family deductibles, it is only a matter of time before billing medical insurance for certain dental procedures will become a required practice.
The bottom line is that an office that is proficient in billing medical insurance will be in demand in the near future. Dentists will see more reimbursements and—best of all—improve the oral and physical health of their patients.
Christine Taxin is the founder and president of Links2Success, a leading cross-coding consulting group that has helped many teams realize the benefit of cross-coding. Taxin can train any dental team how to bill properly in order to see success. More information about Links2Success is available at www.links2success.biz.
