How your oral surgery is covered by medical insurance depends upon the nature and reimbursement rates used by both plans, given how claims for both medical and dental coverage differ significantly.
Most traditional and HMO medical plans provide coverage for dental-involved surgeries for treatment of fractures, dislocations and facial wounds/lacerations. Click here to find out more information regarding this coverage.
What Is Covered?
Medical insurance provides coverage for illnesses, injuries and ailments that require treatment. It encompasses an array of treatments and services including oral surgery; however, understanding the differences between medical and dental coverage could have a substantial effect on your ability to get reimbursed for certain procedures.
Uninformed dental insurance policy holders sometimes assume they don’t require additional medical coverage if they purchase dental coverage; however, this assumption can prove fatal if undergoing more invasive dental procedures like oral surgery.
Defining medical and dental coverage can be complex. Determining a particular procedure’s coverage depends on a range of factors, including what kind of surgery you require and why you require it. Dental and medical plans each have their own rules regarding which procedures qualify as either medical or dental, which can differ between insurers.
Medically necessary oral surgery will typically be covered by medical insurance plans; elective surgery won’t. Examples of necessary surgeries could include the removal of bone-impacted teeth and treating oral cancer or TMJ disorder; it could also be used to address complications from other medical conditions like cysts or infections in the mouth or jaw.
Dental insurance typically only covers oral surgery when it is deemed essential to the overall health and wellbeing of its patient, such as in cases requiring complex wisdom tooth extraction that cannot be accomplished using traditional dental methods or for TMJ-related issues that necessitate reconstructive jaw surgery.
If a dentist or oral surgeon determines that oral surgery is medically necessary, they typically bill medical insurance first before submitting claims to dental insurers later – this practice is known as first-dollar coverage.
Your medical insurance may impose an annual maximum limit for covering dental or oral surgery costs, meaning if you’re not careful when scheduling procedures you could end up owing a substantial bill from your provider and surgeon. Therefore it is vitally important that before beginning any procedures including oral surgery consultation is held with both parties involved – specifically with their financial staffs and surgeons.
Is It Medically Necessary?
Decisions on coverage for oral surgery – as well as out of pocket costs associated with it – are typically decided by one’s medical insurance provider, as many individuals maintain separate dental and medical coverage plans. Many health plans have deductibles/co-pays that must be met prior to treatments being covered; additionally there may be flat copayments required for certain services like prescription drugs.
Dental coverage, typically offered through employee-sponsored plans or individual dental insurance policies, can be beneficial to many. Dental coverage helps lower or eliminate treatment costs for common issues like cavities, fractured teeth and tooth loss; and can even assist in covering more expensive procedures like wisdom tooth removal and jaw reconstructions.
Medical insurance typically provides coverage for more significant dental health concerns that affect the mouth, such as gum disease, infections and cancers. It may also cover procedures which improve overall health – for example replacing lost teeth with implants or treating sleep apnea through cleft palate surgery.
Medically necessary oral procedures often come at a higher price tag. For example, dentists might advise extracting teeth due to serious dental conditions like gum disease or to treat complications from other medical treatments (like heart surgery).
Note that original Medicare (Part A hospitalization coverage and Part B outpatient coverage) does not consider dental or oral surgery services “medically necessary,” though private insurers may offer Medicare Advantage plans with dental coverage.
If you are uncertain if your medical insurance will cover the cost of oral or maxillofacial surgery, speak to the financial team at your dental office for more information. They can offer payment policies and low or no interest financing solutions as well as provide a detailed estimate of total surgery cost including any applicable deductibles, copayments and/or coinsurance premiums.
Do I Need to See an Oral Surgeon?
Dental-related procedures covered by your medical insurance are an invaluable asset, but it’s crucial that you understand which treatments are and aren’t covered in order to avoid unanticipated out-of-pocket expenses.
Medical insurance typically only covers oral surgery when it is considered “medically necessary,” meaning the procedure must improve or maintain overall health and wellbeing for an individual. Accidents or injuries often necessitate oral surgery; alternatively, some medical conditions, like sleep apnea, may necessitate surgical treatments to alleviate symptoms.
Medical insurance policies often cover oral and maxillofacial surgery if nonsurgical treatments fail to help resolve an individual’s condition, for instance those suffering from sleep disorders that fail treatment with CPAP machines may qualify for surgical options as an avenue to healing.
Oral surgeons specialize in performing various dental surgical procedures, from extractions and implant placements to jaw fracture repairs and soft tissue biopsies. An oral surgeon may also offer various anesthetic options such as general anesthesia, nitrous oxide sedation or IV sedation for less invasive procedures.
If you are uncertain whether your upcoming oral surgery will be covered by your health or dental plan, speak to an experienced oral surgeon who can discuss all the factors which could have an effect on its coverage, such as which codes your insurer uses when assessing procedures and their impact on reimbursement rates.
Be mindful that many dental and medical insurance plans overlap, covering different aspects of care. This may lead to confusion as to where coverage lies for specific treatments; so it’s wise to read your policy or contact an insurance representative in order to better understand your coverage and financial responsibilities before making decisions about oral surgery procedures. This will enable you to avoid unexpected out-of-pocket expenses while making informed choices.
Do I Need to Submit a Claim?
As with any insurance coverage, Blue Cross policies contain certain limitations and restrictions that can impact how patients will be reimbursed. To understand their terms and conditions properly, contact your Blue Cross representative directly or review your policy documents to learn about any applicable policies or terms and conditions. Generally, dental surgeries covered by medical insurance when deemed essential to treating an underlying medical issue; cosmetic procedures typically won’t.
Decidng whether a procedure should be considered medical or dental can depend on several different criteria, including whether or not treatment is medically necessary. Claims filed using codes specific to both specialties indicate surgery type, complexity level, which tooth it involves and any necessary anesthetic requirements as well as any reimbursement policies applicable – it’s up to claim filers to use appropriate codes in their claim filing to ensure they receive appropriate reimbursement from insurance policies.
Once a person decides to undergo oral surgery, it’s essential that their medical insurance provider be informed. Gross notes that some providers have strict rules about what dental services they cover and it’s therefore imperative that before scheduling treatment it be checked with your dentist or oral surgeon whether they can bill for it through your health plan.
Many dental clinics employ financial staff members specially trained in processing medical insurance claims quickly and accurately, should a patient owe any fees associated with treatment, these professionals work with them to devise an affordable monthly payment plan. At Oral & Maxillofacial Surgery of Utah, it’s our priority to ensure patients get access to timely healthcare they require, even when this means working with medical insurance providers on outstanding claims.
Before beginning any type of treatment, especially oral surgery, it’s essential to fully comprehend your insurance coverage. By researching dental vs medical plans and understanding their advantages and disadvantages, it can help ensure your procedure will both necessary and worthwhile.
