When you see patients for oral health care, it can sometimes be challenging to determine whether to bill their visit under their dental insurance or their medical plan. But understanding the nuances of each type of coverage can help every practice make the right choice.
Consider these best practices when differentiating if you should bill medical or dental insurance.
Dental Insurance Is a Slight Misnomer
Although your practice and your patients are likely to refer to dental coverage as “dental insurance,” that’s actually a slight misnomer. Dental insurance is considered more of a benefit or a healthcare financing option than an actual insurance program, experts say.
Dental insurance is paid based on a negotiated contract between the patient’s employer and insurance company, with varying rates of reimbursement and coverage criteria. In most cases, the maximum benefit is between $1,500 and $2,000 per year per patient.
Medical insurance, on the other hand, is more of a true insurance program, which typically have set rates that don’t vary dramatically from one employer to the next. In some cases, medical insurance has maximum coverage limits upwards of $1 million, and some are even unlimited.
When Does Medical Insurance Pay?
Most medical insurance plans will consider an examination of the head, neck, oral cavity and surrounding structures payable if it’s for a medically necessary reason. Medical insurance won’t pay for preventive dental care or dental hygiene/cleaning visits, but it may cover other services (depending on the plan), such as:
- CT scans of the head and neck
- Some oral surgeries
- Biopsies of the mouth
- Some services to treat TMJ
- Repair or reconstruction to trauma affecting the mouth
- Advanced oral cancer screenings
Check with your patient’s medical insurer about which oral care services they’ll cover. If they do cover certain oral care services, determine whether you should report those visits with CPT codes or CDT (dental) codes.
What Does Dental Insurance Pay?
As noted above, dental insurance coverage is often employer-specific, but in most cases, it will pay for such services as:
- Two preventive visits per year
- Fillings
- Restorative care
- Root canals
- Crowns
- Oral exams
- Extractions
- Dental hygiene and fluoride treatment
- Treatment of gum diseases
In most cases, cosmetic dental services (such as teeth whitening or veneers) won’t be covered by medical insurance or dental insurance, and will be the responsibility of the patient to pay. However, this may vary based on coverage and the patient’s condition. For instance, if a patient’s teeth are affected by cancer treatments like chemotherapy, some medical insurers may cover specific procedures to restore the appearance of their teeth to match the teeth that weren’t affected. Again, this will vary based on the plan.
Seeking more information about which insurance to bill for dental patients? Let expert Kathy S. Forbes, RDH, BS, FADHA walk you through it during her recent online training, Dental Hygiene CDT Code Accuracy & Payment Results. Sign up today!
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