The Loop

Dental Medical Bills

Filed under: Benefits

Is dental insurance a good value? Many people buy it because it often covers two preventive care check-ups a year. For those who receive an employer-subsidized plan through work, this benefit can be significantly less expensive than paying out-of-pocket for the cost of cleanings and x-rays.

However, with many dental insurance plans, the benefit beyond standard care is negligible. Standard coverage generally includes x-rays, cleanings, fillings and other routine care – such as fluoride treatments for children. However, when more complex procedures are required, such as a crown, root canal, or bridge work, insurance may cover only 50 percent of the cost. Some procedures, like dental implants, may not be covered at all.

Worse yet, most dental insurance plans have annual caps, so payment for procedures that are covered may be limited to $1,000 or $1,500 a year. For dental patients who must undergo a significant amount of work – even those with coverage – they could still end up paying thousands of dollars out-of-pocket.

Medical Insurance Solution
To help mitigate the expense of dental care, some patients may be able to use their health insurance to pay for at least a portion of the cost. While covered services vary by policy, those that do cover dental work typically mandate that the cause of the ailment be an underlying medical condition. For example, dental repair due to an injury, conditions associated with inflammation or infection, some periodontal surgery procedures, and even appliances prescribed for sleep apnea.

A general rule of thumb is that dental insurance covers procedures involving teeth, while health insurance is more apt to cover care related to the head, neck and mouth. In many cases, a dentist may perform a combination of dental and health insurance-covered services, particularly when he first sees a new patient. In this scenario, it's possible to file claims with both types of insurers to receive maximum coverage.

Medical Services Provided by Dentists
According to the California Dental Association, there is a vast spectrum of procedures that dentists routinely perform that are considered "medically necessary". The following is a partial list of services that may qualify for health insurance coverage:

• CT scan of mouth and jaw bone
• Panorex x-rays
• Cone beam computed tomography (CBCT)
• Oral infections, cysts, oral inflammation
• Sleep apnea appliances
• Temporomandibular disorder (TMJ) appliances and headache treatment
• Accidents to teeth
• Mucositis and stomatitis (caused by chemotherapy and other treatments)
• Frenectomy/tongue tie for infants and children
• Facial pain treatment
• Dental implants and bone grafts
• 3rd molars or wisdom teeth extraction
• Biopsies
• Clearance exams before chemotherapy or surgery
• Botox Injections for bruxism and jaw pain

Billing Process
In scenarios that involve more than tooth repair, it is recommended to file the first claim with the patient's health insurer. Once that claim has been paid (or rejected), then bill the dental plan for whatever balance remains. More and more dentist offices are learning about this strategy – to their advantage – as medical claims tend to pay a higher reimbursement than dental insurers for the same service.

For example, one dentist bills medical plans $744 for a CT scan, from which he is paid on average about $500. By contrast, dental insurance plans pay out an average of only $125 for the same screening, although many plans do not cover CT scans at all.

Bear in mind that a patient can file claims for medical reimbursement if his dentist will not.

Review Health Insurance Policy
As a general rule, health insurance reimburses many procedures that dentists perform on if they are considered medically necessary. However, the first step to figuring out if a health insurance plan will cover dental procedures is for the patient to read his individual policy. Plan documents typically detail what services are covered, at what rate or percentage level, as well as a comprehensive list of what procedures, services and equipment are excluded from policy coverage.

Dental Emergencies
Bear in mind that health insurance is complex even for medical conditions, let alone dental emergencies. According to the American Academy of Pediatric Dentistry, health insurance generally covers procedures associated with dental emergencies that involve restoring sound natural teeth. A natural tooth is defined as stable, functional, firmly attached to the jawbone, free from decay and advanced periodontal disease, and intact at the time of the accident. However, be aware that the definition of a sound natural tooth may vary from carrier to carrier.

Also, it's important to understand the health insurance plan's criteria for dental services, such as pre-authorization, limits to coverage for each plan year, and coverage for emergencies. For example, some policies provide coverage only for dental emergencies that receive treatment
within the first 24 hours of the accident or only up to 72 hours. Others may limit the dollar amount of coverage and/or apply a separate deductible for emergencies. There also may be a limited timeframe to complete treatments for trauma-related dental services, such as six months or a year.

These criteria make it critically important to read the individual health insurance policy thoroughly and even contact the carrier with specific questions regarding coverage for dental care.

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