If Insurance Doesnít Cover It, I Donít Want It!
The more things change, the more they stay the same. A cliché that many facts support - particularly in the arena of dental insurance benefits. While massive changes are occurring in the insurance coverage business market, changes in dental benefits appear to be slow to advance. While it is true that most states are accommodating Medicaid expansion, which includes more dental coverage for adults, right now there are not enough Medicaid provider dentists to cover existing pedo patients, let alone more adults. If Medicaid benefit payments increase, this will likely change. But it will probably be several years before we know what the increases entail or if improvement in payments actually happen at all.
In addition, private dental plans may “someday” provide better benefits. For now, employer driven benefit plans remain fairly consistent. Maximums are stuck at around $1200 annually, and restrictive rules as to coverage for specific treatment continue to effectively limit what many patients receive. While some patients can afford whatever treatment they require regardless of insurance, many cannot. So we are left with a problem that has persisted for years; that of patients refusing treatment not covered by their insurance.
As a hygienist, this is a continual issue. Patients who we identify as needing periodontal scaling may refuse. They may not fully understand what we are recommending and why. They may not want to spend the time necessary for treatment, or they may not think that insurance will cover it. The good news is that most plans DO cover perio scaling. Plans typically will cover the 1-3 teeth or 4 or more teeth per quadrant options once every three to five years. The criteria for coverage is not complicated, but must be documented for payment to be allowed. A pocket of at least 4mm on at least one surface of each tooth designated for treatment is required. Documentation of bleeding, furcations, recession and mobility may also be requested. A diagnosis is important as well. Many carriers accept the older version of diagnoses such as Case Type II Moderate Periodontal Disease, while others are looking for the newer version as described by the American Academy of Periodontology, such as Chronic Periodontitis, Generalized.
So, we know that perio scaling is covered, but what about periodontal maintenance? Most plans will cover maintenance only twice per year, whereas most patients need the service three to four times annually. Here is where acceptance problems may crop up. A patient may tell us that he wants only the two covered maintenance visits a year. The insurance carrier may confuse the issue by telling the patient that if his dental office codes the other two maintenance visits as prophys, insurance will cover them. We know that alternating D4910 Periodontal Maintenance and D1110 Adult Prophy makes no sense. One is for a periodontally compromised person; the other is for a healthy adult with no pockets.
Education can help our patients understand why more frequent appointments are needed, even if their insurance will not provide a benefit. And we owe them every effort to explain. But more importantly, we need to demonstrate the differences between a standard prophy and periodontal maintenance so patients don’t think they are receiving the same service at just a higher fee. If patients can’t perceive any difference, why should they come more often, plus pay out-of-pocket? We need to be sure that we are observing the standards for periodontal maintenance and that our patients know it.
This means that every D4910 includes full mouth perio charting and recording, including bleeding, furcations, mobility and recession. Printing out a copy of this charting for the patient to take home is also helpful. If sulcular irrigation is needed, this should be done as part of the appointment and the patient should know what the irrigant is and why we are using it. Isolated areas of root planing may also be required and we should tell the patient why we are performing this. Most patients expect a polish at the end of the appointment, and if appropriate, this can be accomplished as well. A slightly longer appointment time is helpful. Rushing periodontal maintenance is not conducive to patient confidence. If the patient needs prescription mouth rinse, consider having this available for sale in the office. It saves the patient from making a stop at the pharmacy and is often appreciated. Keep in mind that at least twice annually the dentist should also perform an evaluation. This evaluation is not considered to be a part of perio maintenance and should be coded separately.
There are patients with insurance who need perio treatment but refuse no matter what we say or do. Should we keep treating these patients with prophys? Should we send them elsewhere? This situation is a matter of office philosophy and everyone in the practice should know what the philosophy entails. For many, keeping the patient in the practice and performing “prophys” with education, probings, photos, and radiographs may ultimately result in the patient accepting perio treatment. If the patient’s insurance covers periodontal scaling, be sure s/he knows this. The front desk staff can talk to the patient about what the benefit might be before s/he leaves. Even after a period of years, some patients will eventually go ahead. We can’t give up.
Doing “just what insurance pays for” can often be a barrier for proper patient care. We owe our patients as much information as we can provide to help them get what they deserve, and often what insurance pays for as well.
Carol Tekavec RDH is the Director of Hygiene for McKenzie Management. Carol can improve your hygiene department in just one day of training “in your office.” Interested in knowing more about how to improve your hygiene department? Email firstname.lastname@example.org.
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