EXORBITANT DENTAL BILL? MEDICAL
INSURANCE MAY COVER SOME OF IT
By David Tuller, Kaiser Health News
On a recent Friday morning, more than
30 dentists and dental staffers gathered
in a conference room to learn an arcane
new skill: how to bill medical insurers.
Pacing back and forth, the Florida
dentist leading the two-day course
advised the participants to stop thinking
of themselves as tooth technicians and
reposition themselves as “physicians of
the mouth.”
“There is a medical part of our practice
and a dental part,” said the presenter,
Dr. Chris Farrugia, a dentist, as audience
members tapped on their keyboards or
scribbled notes. “You have teeth, you got
the ‘other stuff.’ It’s the other stuff that
medical insurance pays for.”
Dr. Farrugia’s seminar is a sign of a
growing trend in dental offices, as
providers seek greater reimbursement
for expensive services and patients balk
at big bills. Around the internet, firms
have popped up claiming expertise in
medical billing for dentists and offering
courses and consulting services.
The reason is simple: Medical insurance
is generally much more generous in its
coverage than dental insurance.
Unlike medical coverage, dental
insurance is mostly geared to the healthy
— something many people don’t realize
until they experience serious oral
problems and get socked with
unexpected costs. Standard dental
insurance covers cleanings, fillings and
other routine care. But major work like a
crown or a bridge is often covered only
at 50 percent, and implants generally
aren’t covered at all. And dental
insurance is usually capped at $1,000 or
$1,500 per year.
As a result, people who require extensive
reconstructive work often pay many
thousands of dollars, or sometimes tens
of thousands, in out-of-pocket expenses.
Many other people, even with dental
coverage, go without care because they
cannot afford the large balances or co-
payments for crowns, root canals and
other major procedures.
Because of these differences in
reimbursement, Dr. Farrugia told his
seminar attendees, dentists should first
consider what medical insurance might
cover and then bill the dental plan for
the rest.
For example, he said, dentists should
seek medical coverage for the full head,
neck and mouth exams they perform
when they see a new patient, since the
goal is to assess more than just the teeth.
Medical insurers should also cover oral
problems attributable to an underlying
medical condition, such as diabetes or
dry mouth, a common side effect of
many medications, Dr. Farrugia said.
Besides sparing patients the pain of big
bills, the strategy can also increase
income for dentists, said Dr. Farrugia,
who estimated that revenues for his
practice rose almost 10 percent the first
year he fully implemented medical
billing. Patients, too, can learn to file
claims for medical reimbursement if
their dentists won’t, he said.
On its website, the California Dental
Association explains that health
insurance should cover costs that are
“medically necessary” and lists more
than a dozen categories of procedures
that could qualify. Among them:
treatment related to inflammation and
infection, dental repair resulting from
injury, certain periodontal surgery
procedures and appliances for sleep
apnea.
Kristine Grow, a spokeswoman for
America’s Health Insurance Plans, the
industry trade association, did not dispute
that some dental procedures could be
covered by medical insurance. However,
she cautioned that medical insurers were
always on the lookout for abuse.
“Claims that are billed inappropriately
or submitted fraudulently hurt everyone
because they raise costs,” Ms. Grow said.
“It’s important to note that procedures
not related to an emergency event or
trauma may not be medically necessary,
and therefore would not be covered by
medical insurance,” she added.
Asked about the potential for abuse, Dr.
Farrugia said: “There are unethical
providers in all health care services, and
dentistry is not immune to that. You will
always have some that try to game the
system.”
Dr. Farrugia adopted medical billing
several years ago after paying more than
$100,000 for a CT scanner that
produces 3-D images of the bone in the
mouth and jaws.
“It occurred to me that this was a
medical device,” he said of the CT
scanner. “I’m a licensed health care
provider, I’m providing this within the
scope of my license. They can’t
discriminate against me.”
Los Angeles Dental Society Explorer