Insurance billing..

[SM156]

Is it ethically wrong to bill an insurance company for an esthetic procedure when you remove a defective restoration? Or can we only bill for the replacement of the original filling?

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[DrJeff]

Is it ethically wrong to bill an insurance company for an esthetic procedure when you remove a defective restoration? Or can we only bill for the replacement of the original filling?

What esthetic procedure are you talking about?? If you're removing an old, defect amalgam on a posterior tooth and replacing it with a composite, there's nothing wrong with that(per archaic thought processes and maximizing THEIR profits, they'll more then likely just re-imburse for the cost of an equivalent amalgam resortation though). If your removing a old class 5 composite on #9 and replacing it with a veneer, well then 99% of the time the insurance company will deny the claim.

The bigger factor here, is your line of thought is one where you as the dentist seem to be wanting to let the insurance company dictate treatment. The ultimate treatment descisions should be between YOU and YOUR PATIENT and if there's some help from the insurance company in paying some of the bill, great. The unfortunate truth is that very often the appropriate treatment for your patient in your clinical opinion WON'T be in agreement with what the data analysis folks at the insurance company think in the appropriate treatment

 

[SM156]

Thanks for the response. Take for instance a large amalgam which encompases the MB cusp of a first maxillary molar. In a perfect smile it can be seen in the buccal corridor. Say you replace that the amalgam with a composite because the patient wants it for esthetic reasons. Do you simply bill for the original amalgam or new cosmetic composite? The restoration could be arguably placed as a functional or cosmetic procedure. It just seems like some grey area that I would like to avoid in case any legal disputes were to ever arise with the insurance company.

 

[aphistis]

Thanks for the response. Take for instance a large amalgam which encompases the MB cusp of a first maxillary molar. In a perfect smile it can be seen in the buccal corridor. Say you replace that the amalgam with a composite because the patient wants it for esthetic reasons. Do you simply bill for the original amalgam or new cosmetic composite? The restoration could be arguably placed as a functional or cosmetic procedure. It just seems like some grey area that I would like to avoid in case any legal disputes were to ever arise with the insurance company.

You bill for the procedures you perform. If the insurance company doesn't agree, they simply won't pay for it. That's why it's so important to settle payment terms with your patients prior to beginning treatment. Absent evidence of insurance fraud, though, they won't spend the time or money necessary to take legal action against you.

Incidentally, if you're replacing that restoration, it shouldn't be with a direct composite. Rebuilding an entire cusp is a lot to ask from a resin. Your patient would be much better off with an indirect restoration in the situation you're describing, if they elect to have the amalgam replaced.

 

[DrJeff]

Thanks for the response. Take for instance a large amalgam which encompases the MB cusp of a first maxillary molar. In a perfect smile it can be seen in the buccal corridor. Say you replace that the amalgam with a composite because the patient wants it for esthetic reasons. Do you simply bill for the original amalgam or new cosmetic composite? The restoration could be arguably placed as a functional or cosmetic procedure. It just seems like some grey area that I would like to avoid in case any legal disputes were to ever arise with the insurance company.

You bill for the procedures you perform. If the insurance company doesn't agree, they simply won't pay for it. That's why it's so important to settle payment terms with your patients prior to beginning treatment. Absent evidence of insurance fraud, though, they won't spend the time or money necessary to take legal action against you.

Incidentally, if you're replacing that restoration, it shouldn't be with a direct composite. Rebuilding an entire cusp is a lot to ask from a resin. Your patient would be much better off with an indirect restoration in the situation you're describing, if they elect to have the amalgam replaced.

Agree with Aphistis!

*If* you are going to do that composite cusp replacement filling AND you're dealing with an insurance compnay, what you bill for (both the insurance company AND the patient) and what you'll get paid for will often very greatly based on your insurance participation and the rules and regulations of the state you practice in.

Basically, some insurance plans that you may participate in might only allow you to bill for the similar sized amalgam restoration and then balance bill the patient upto the amalgam fee (I.E. if you do a MOB composite on #19 and your fee is $200. The insurance company might only allow you to charge the patient for the equivalent sized amalgam fee(say $150), and then they'll re-imburse you $130{the customary 80% of their usual fee} and you can bill the patient the remaining $20 and contractually write off $50 difference between the amalgam and composite fees) Confusing, YUP. Now to add even more confusion, with some insurance companies, and insome states, with the same scenario, you're allowed to bill the patient the extra $70 to reach your regular composite fee

 

[KOM]

Now to add even more confusion, with some insurance companies, and insome states, with the same scenario, you're allowed to bill the patient the extra $70 to reach your regular composite fee

Like Alaska? Which states? 100% reimbursement - that's where I want to practice!

 

[DrJeff]

Like Alaska? Which states? 100% reimbursement - that's where I want to practice!

CT lets me fully balance bill