Billing Medical and Dental Insurance Companies
Dental practices can bill medical insurance to help their patients receive more coverage. Though, in addition, practices may need to bill dental insurance. In this case, they have to follow particular billing processes.
The practice must adhere to different claim submission procedures. Some treatments, such as those performed by oral and maxillofacial surgeons and “incision and drainage of abscess of the intraoral soft tissue,” could be billed to either dental or medical insurance (“Dental Insurance Billing and Coding Basics;” Taxin 2015). The staff may bill some of these treatments to medical insurance in order to help prevent patients from reaching their annual maximums in dental insurance early (Taxin 2009). Consequently, patients can utilize their dental benefits for dental procedures (Taxin 2009).
When a dentist performs treatment categorized under medical, his or her practice usually bills it to the medical insurance company first because “the medical plan is primary” (“ADA Guidance on Coordination of Benefits” 1; Philhower and Blair 2016). Though, in some states, the primary plan is the “plan that does not contain order of benefit determination provisions…” (Taxin 2015). Albeit, when medical and dental insurance “do not have a coordination of benefits clause,” dentists should analyze whether the patient’s condition involves medical aspects in order to bill medical insurance first (Taxin 2015). The practice should check “which plan is primary” before billing any procedures (Taxin 2015).
Some dental insurance companies, such as Delta Dental and Aetna, “require a medical plan DENIAL before paying for surgery, pathology, and appliances” (Zahrebelny, Inclusive Magazine 2014). After the medical insurance company examines the claim, the practice then sends a claim along with the medical explanation of benefits to the dental insurance company (Philhower and Blair 2016). Meanwhile, treatments performed on the teeth, “not involving traumatic injury,” should be sent to dental insurance (Zahrebelny). Otherwise, when the practice sends claims to both medical and dental insurance at the same time, they may receive an overpayment, which “may be considered fraud and abuse and may be punishable by monetary means” (Philhower and Blair 2016; Taxin 2015).
The practice may have to send “refunds to the payer(s) and/or patient” (Philhower and Blair 2016). It could bill both medical and dental plans, if “both insurance plans are the same carrier, such as Aetna medical and Aetna dental” (Taxin 2015). Practices could bill certain services to medical and dental plans at the same time so long as the insurance companies are aware of each other on their claims (Taxin 2013; Zahrebelny). For instance, for “large, comprehensive” treatment plans, the practice can send claims with the diagnostics to medical and dental plans “in order to satisfy the medical deductible” (Taxin 2013). By doing so, patients could receive “maximum coverage for the surgical portion of treatment, such as periodontal and implant services” (Zahrebelny).
Submitting claims to both medical and dental insurance can be a complex process for the practice. But, when the practice succeeds in this process, patients can receive much coverage that helps them pay for treatment (Zahrebelny).
“ADA Guidance on Coordination of Benefits.” American Dental Association.
Accessed January 17, 2019.
Philhower, Jim and Charles Blair. “Submitting dental procedures to medical insurance has been
voodoo—until now.” Dental Economics, September 22, 2016.
“Dental Insurance Billing and Coding Basics.” MB-Guide. Accessed January 17, 2019.
Taxin, Christine. “Converting dental to medical billing.” DentistryiQ, January 17, 2013.
Taxin, Christine. “Coordination of Benefits.” Find-A-Code, September 25, 2015.
Taxin, Christine. “Keeping Your Practice Healthy: Medical Billing in Dental Practices.”
DentistryiQ, November 18, 2009. https://www.dentistryiq.com/articles/2009/11/keeping-your-practice.html.
Zahrebelny, Olya. “Billing Patient Medical Plans: There’s Nothing Illegal About It!” Glidewell
Laboratories. Inclusive Magazine 2, no. 1. Accessed January 17, 2019.
Zahrebelny, Olya, Inclusive Magazine. “Billing Patient Medical Plans: There’s Nothing Illegal
About it! (Vol. 2, Issue 1).” YouTube Video, 25:34. September 5, 2014. https://www.youtube.com/watch?time_continue=1528&v=fw56BbDRTjw.