To Inlay, to Onlay, or to Crown?
My question concerns billing insurance for inlays and onlays. I call the benefits administrator and find out that inlays are a covered benefit, but when I submit for payment it is often paid at an alternate benefit of an amalgam or sometimes a posterior composite. The patient is always upset when the payment is not what they expected. Is there a way to guarantee a more accurate outcome for this situation? Should we just crown the tooth and get paid?
Betsy, Business Coordinator
The information you receive from the benefits administrator has little to do with the final payment. This information is always qualified with a statement of “this is not a guarantee of payment.” An inlay may be on the list of covered benefits, but it is subject to review from a dental professional paid by the insurance company before the check is drawn. This review may result in a decision to allow for an alternate benefit or a complete rejection.
Each insurance company has a different criterion for consideration of payment for restorations. An amalgam filling is still considered to be a satisfactory and long-lasting restoration, despite the popular and supported opinion that an inlay is less invasive, better fitting and less stressful on the remaining tooth structure. A cast inlay also lasts longer and does not stain or wash out over time. The issue here is what the patient wants. Does the patient want an adequate, less expensive amalgam or composite, or a nice cast restoration? If the answer is an inlay, you can have a three-way conversation with the insurance company administrator to get clarity on how the inlay billing will be handled. You must also have an understanding from the patient that s/he is proceeding with the assumption that s/he will have to pay for the difference between the filling and the inlay.
It is often said that a “good narrative” is the answer to getting paid. Were it that simple, all inlays would be paid. A narrative is necessary for proper documentation of the procedure, but again does not guarantee payment. A pre-authorization will clarify whether the inlay is a benefit of a particular policy, and though there isn’t a guarantee, most of the time the payment will come through when billed.
An inlay is not the same as an onlay and an onlay is not the same as a ¾ crown. An inlay is a restoration that lies within the cusps of the tooth and is fabricated from an impression, to correspond to the form of the prepared cavity area. The restoration is then cemented or light-cured into the tooth creating an excellent bond. An inlay restores portions of a tooth that might also be restored using amalgam or composites.
An onlay is made and placed the same way, but its purpose is to also replace the cusp or cusps of a tooth. An onlay must have the inlay component in addition to the onlay that is replacing a missing or fractured cusp. In the narrative, you must mention the fractured cusp or cusps to be paid for an onlay. Often an x-ray will not sufficiently demonstrate the defect in the tooth requiring an inlay or onlay. An intraoral photo properly labeled with name and date of birth of the patient with arrows pointing to the fractures and defects within the floor of the tooth helps. Some insurance companies do not accept intraoral photos, so a proper narrative is imperative.
The preauthorization request should contain a narrative explaining why an inlay or onlay is the best treatment, as well as an attachment of pertinent documentation such as an x-ray and an intraoral photo. Example:
(1) Existing restoration is an occlusal composite with recurrent decay. Vertical fracture lines are apparent on #12. The patient describes the tooth as painful to chewing. An inlay will strengthen the tooth and not stress the fracture lines.
(2) Existing restoration on tooth #2 is an MOD amalgam with decay undermining cusps on DL and MF. Eighty percent of the cusp incline for these cusps is involved. An onlay will restore the tooth to function by replacing the cusps and strengthening the tooth. The onlay will also facilitate flossing between the teeth as it will be a better fitting, smoother surface.
If the tooth has sufficient decay, fractured cusps, broken or defective restorations, and other fractures involving at least four surfaces, a crown would be the best restoration. Performing and billing crowns that are not warranted because of the higher chance of being paid by the insurance company is fraudulent and unethical. Most importantly, have your patient involved in the decisions regarding their dental work, and they will not feel victimized by you when payment is due.
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