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Reimbursement for dental implants
o you think that your patient’s dental insurance does not cover implants? Think again. Many dentists are not aware that dental insurance may provide benefits for some portion of implant therapy in certain cases. Because of this lack of awareness, dentists and patients may not be receiving all that dental plans provide in terms of reimbursement. Although it is true that, for a variety of Some dentists reasons, many plans do not cover the surand patients gical portion of implant therapy, some carriers do provide benefits for the restoramay assume tion of implants. Therefore, if an insurance incorrectly that company states that it does not cover a dental dental implants, that may mean only that insurance plan the surgical aspect of the treatment is not does not covered. Unfortunately, many dentists and reimburse for patients give up when they hear that implants are not covered and do not any implant submit claims for benefits that may be therapy when available for the restorative portion of the there may be therapy. some benefit Because implant therapy requires both surgical and restorative treatment, manavailable. aging the reimbursement process may be somewhat more complicated than it is for other therapies. This can lead to confusion on the part of the dental office and the patient and, in some cases, may mean that neither is receiving the full benefits provided by the patient’s dental plan.
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TYPES AND LEVELS OF REIMBURSEMENT
Types and levels of reimbursement for the surgical portion of implant therapy vary widely. A few plans do provide benefits for both the surgical and the restorative 210
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MAXWELL H. ANDERSON, D.D.S., M.S., M.Ed.
T
Dispelling some popular myths
Background and Overview. Dental implants are being placed with increasing regularity. Many dentists do not take A D A J advantage of insurance coverages for this ✷ ✷ treatment because they are under the impression that no aspect of implant therapy is covered. This article discusses a N C U U Imay number of insurance benefits A that be D N 1 RT G E available to dental patients but not Ireadily CLE apparent to treating dentists and their staff members. Conclusions and Practice Implications. Some dentists and patients may assume incorrectly that a dental insurance plan does not reimburse for any implant therapy when, in fact, there may be some benefit available for at least a portion of the treatment. In addition, some dentists and patients may not consider implant therapy even when it is the preferred treatment option because of the assumed lack of reimbursement. Knowing that some reimbursement is available may make the difference in the patient’s accepting the best treatment for his or her condition. Furthermore, since an increasing number of patients now make some contribution toward their dental insurance plan premiums, they deserve to know their options and to receive appropriate benefits. Key Words. Dental implants; dental insurance; reimbursement. CON
Reimbursement for dental implants
ABSTRACT
T
M A N A G E M E N T
A
P R A C T I C E
aspects of dental implants, up to an annual or lifetime maximum. Other plans cover implants as a part of special riders that purchasers may include in their plans. Still others cover surgical and restorative aspects of implant therapy in specific cases (such as single-tooth implants in lieu of a three-unit bridge in cases in which the adjacent teeth are not compromised). On the other hand, many plans provide some level of reimbursement for the restoration of implants as part of the plan’s prosthetic coverage. Once a dental team places an implant, then insurance plans may provide benefits for restoring the implant in a manner
JADA, Vol. 136, February 2005 Copyright ©2005 American Dental Association. All rights reserved.
P R A C T I C E
similar to that in which natural teeth are restored. Often, dentists and patients assume that because the patient’s dental plan has an exclusion for the surgical portion of the implant therapy, there is no benefit for the restoration of an implant. This may not be the case. Most dentists and patients ask whether implants are covered and, when they hear “no,” assume that there is no purpose in submitting claims for any of the treatment costs. In fact, if the dentist follows the procedures outlined by the insurance company for getting reimbursement and is clear about the case and the need for implant restoration, many insurance companies provide some benefit. The insurance companies sometimes do require additional information about the case (such as the number of missing teeth and extraction dates) but will reimburse the restoration of an implant at the same percentage as a traditional restoration such as a crown or a partial denture. A plan may apply an alternate benefit, such as a pontic instead of a crown, even though the dentist is placing an implant-supported crown or prosthesis. To receive the maximum reimbursement, the dentist should work closely with the insurance company to ensure that the company’s claims reviewer is clear about the need for the treatment and the appropriateness of the case. HOW TO HANDLE IMPLANT REIMBURSEMENT
Following are some tips on handling reimbursement of implants with dental insurance companies. dBe sure you fully understand what is and what is not covered relative to implant therapy since, as I mentioned earlier, plan benefits vary considerably. Do not assume that an implant exclusion means there is no benefit for any portion of the treatment. dGet clarification about coverage for implant restoration, as opposed to coverage for the surgical portion of the therapy. Many plans cover some
M A N A G E M E N T
portion of the restoration of the implant even if they do not reimburse for the surgical portion. dAsk about “alternate benefits” for implant restoration. Plans that do not provide benefits for implants may provide an alternate benefit. dBe sure that you have coded the procedure correctly, according to the most current version of the Current Dental Terminology (CDT) manual (at present, CDT 20051). Some companies consider any restoration of an implant to be, by definition, a “pontic” and not a “crown” because the natural tooth has been extracted. Other insurance plan limitations on prosthetics might stipulate when the tooth was extracted and when any other prior prosthesis was placed. The CDT 2005 code series D6000 through D6199—which covers implant services, related prosthetics and other implant-related services—may be especially useful when coding for these procedures. CONCLUSION
Some dentists and patients may assume incorrectly that a dental insurance plan does not reimburse for any implant therapy when, in fact, there may be some benefit available for at least a portion of the treatment. In addition, some dentists and patients may not be considering implant therapy even when it is the preferred treatment option because of the assumed lack of reimbursement. Even if implant therapy still requires an out-of-pocket investment on the patient’s part, if the case is appropriate for the therapy, knowing that some reimbursement is available may make the difference in the patient’s accepting the best treatment for his or her condition. Furthermore, since an increasing number of patients now make some contribution toward their dental insurance plan premiums, they certainly deserve to know their options and to receive appropriate benefits. ■ Dr. Anderson is vice president and dental director, Washington Dental Service (A Delta Dental Plan), 9706 Fourth Ave. N.E., Seattle, Wash. 98115, e-mail “[email protected]”. Address reprint requests to Dr. Anderson. 1. CDT 2005: Current dental terminology. 5th ed. Chicago: American Dental Association; 2004.
JADA, Vol. 136, February 2005 Copyright ©2005 American Dental Association. All rights reserved.
211
S
TYPES AND LEVELS OF REIMBURSEMENT
Types and levels of reimbursement for the surgical portion of implant therapy vary widely. A few plans do provide benefits for both the surgical and the restorative 210
IO N
I
MAXWELL H. ANDERSON, D.D.S., M.S., M.Ed.
T
Dispelling some popular myths
Background and Overview. Dental implants are being placed with increasing regularity. Many dentists do not take A D A J advantage of insurance coverages for this ✷ ✷ treatment because they are under the impression that no aspect of implant therapy is covered. This article discusses a N C U U Imay number of insurance benefits A that be D N 1 RT G E available to dental patients but not Ireadily CLE apparent to treating dentists and their staff members. Conclusions and Practice Implications. Some dentists and patients may assume incorrectly that a dental insurance plan does not reimburse for any implant therapy when, in fact, there may be some benefit available for at least a portion of the treatment. In addition, some dentists and patients may not consider implant therapy even when it is the preferred treatment option because of the assumed lack of reimbursement. Knowing that some reimbursement is available may make the difference in the patient’s accepting the best treatment for his or her condition. Furthermore, since an increasing number of patients now make some contribution toward their dental insurance plan premiums, they deserve to know their options and to receive appropriate benefits. Key Words. Dental implants; dental insurance; reimbursement. CON
Reimbursement for dental implants
ABSTRACT
T
M A N A G E M E N T
A
P R A C T I C E
aspects of dental implants, up to an annual or lifetime maximum. Other plans cover implants as a part of special riders that purchasers may include in their plans. Still others cover surgical and restorative aspects of implant therapy in specific cases (such as single-tooth implants in lieu of a three-unit bridge in cases in which the adjacent teeth are not compromised). On the other hand, many plans provide some level of reimbursement for the restoration of implants as part of the plan’s prosthetic coverage. Once a dental team places an implant, then insurance plans may provide benefits for restoring the implant in a manner
JADA, Vol. 136, February 2005 Copyright ©2005 American Dental Association. All rights reserved.
P R A C T I C E
similar to that in which natural teeth are restored. Often, dentists and patients assume that because the patient’s dental plan has an exclusion for the surgical portion of the implant therapy, there is no benefit for the restoration of an implant. This may not be the case. Most dentists and patients ask whether implants are covered and, when they hear “no,” assume that there is no purpose in submitting claims for any of the treatment costs. In fact, if the dentist follows the procedures outlined by the insurance company for getting reimbursement and is clear about the case and the need for implant restoration, many insurance companies provide some benefit. The insurance companies sometimes do require additional information about the case (such as the number of missing teeth and extraction dates) but will reimburse the restoration of an implant at the same percentage as a traditional restoration such as a crown or a partial denture. A plan may apply an alternate benefit, such as a pontic instead of a crown, even though the dentist is placing an implant-supported crown or prosthesis. To receive the maximum reimbursement, the dentist should work closely with the insurance company to ensure that the company’s claims reviewer is clear about the need for the treatment and the appropriateness of the case. HOW TO HANDLE IMPLANT REIMBURSEMENT
Following are some tips on handling reimbursement of implants with dental insurance companies. dBe sure you fully understand what is and what is not covered relative to implant therapy since, as I mentioned earlier, plan benefits vary considerably. Do not assume that an implant exclusion means there is no benefit for any portion of the treatment. dGet clarification about coverage for implant restoration, as opposed to coverage for the surgical portion of the therapy. Many plans cover some
M A N A G E M E N T
portion of the restoration of the implant even if they do not reimburse for the surgical portion. dAsk about “alternate benefits” for implant restoration. Plans that do not provide benefits for implants may provide an alternate benefit. dBe sure that you have coded the procedure correctly, according to the most current version of the Current Dental Terminology (CDT) manual (at present, CDT 20051). Some companies consider any restoration of an implant to be, by definition, a “pontic” and not a “crown” because the natural tooth has been extracted. Other insurance plan limitations on prosthetics might stipulate when the tooth was extracted and when any other prior prosthesis was placed. The CDT 2005 code series D6000 through D6199—which covers implant services, related prosthetics and other implant-related services—may be especially useful when coding for these procedures. CONCLUSION
Some dentists and patients may assume incorrectly that a dental insurance plan does not reimburse for any implant therapy when, in fact, there may be some benefit available for at least a portion of the treatment. In addition, some dentists and patients may not be considering implant therapy even when it is the preferred treatment option because of the assumed lack of reimbursement. Even if implant therapy still requires an out-of-pocket investment on the patient’s part, if the case is appropriate for the therapy, knowing that some reimbursement is available may make the difference in the patient’s accepting the best treatment for his or her condition. Furthermore, since an increasing number of patients now make some contribution toward their dental insurance plan premiums, they certainly deserve to know their options and to receive appropriate benefits. ■ Dr. Anderson is vice president and dental director, Washington Dental Service (A Delta Dental Plan), 9706 Fourth Ave. N.E., Seattle, Wash. 98115, e-mail “[email protected]”. Address reprint requests to Dr. Anderson. 1. CDT 2005: Current dental terminology. 5th ed. Chicago: American Dental Association; 2004.
JADA, Vol. 136, February 2005 Copyright ©2005 American Dental Association. All rights reserved.
211