Your Insurance and You: As Told By Me

Did you know I got a job? Yep, way back in May. It’s a wonderful fit for me, but not unlike any other job, it has its moments where I’m panting “TGIF TGIF TGIF” by Thursday afternoon.

First of all I work for an o r @ l surgeon. I’m not just talking a fancy dentist, I’m talking maxillofacial surgeon, the peel-the-face-off-of-someone-to-put-their-bones-back-together-if-in-a-disfiguring-accident type of surgeon. But as exciting as that might sound, those cases are extremely rare around here. Generally speaking, the main thing we get to do around here is surgically remove teeth.

My responsibility is the handling of the insurance and finances, and in today’s insurance climate, it’s fraught with issues and policy holders are left either dumbfounded in confusion or boiling over in indignation.

First of all, I am going to preface this with a statement I have to tell clients every day: I don’t know what your insurance will cover or pay. Policy holders who get pissy about this really need to take a look in the mirror. If YOU have an insurance policy and YOU are paying the policy and YOU elect to take the coverage, then YOU are ultimately responsible for knowing what your insurance will pay and what they won’t. As a courtesy, I will verify coverage, remaining deductibles, coinsurance and even get a quote of benefits for you, but, and that’s a mighty big “But” (…I like big BUTTS and I cannot lie…) the information I obtain from YOUR insurance company and pass back to you is only as good as the representative I talk to on the phone at YOUR insurance company.

If you are referred to my boss for “0ral surgery”, that term does not always mean what you think it means. If you said “0ral surgery” to your medical insurance, that could be taken to mean to mean something as complicated as an osteotomy, which is where a surgeon breaks your face and realigns it. Then your insurance company may believe that it’s to give you a physically more appealing profile (like in a case of “weak jaw”) as an enhancement. OR, it could mean correcting a congenital defect or even a progressive defect in which the lower jaw is undersized or doesn’t grow at the same rate as the rest of the face.

On the other hand, 0ral surgery could mean the surgical removal of a tooth instead of simply extracting it with some fancy pliers.

And that’s why your medical insurance doesn’t normally cover 0ral surgery because they consider it dental. BIG TIP #1: To find out if your insurance will cover 0ral surgery, call and ask them: “Are there any benefits for the SURGICAL REMOVAL of a tooth?” Now they may ask you if it’s impacted or erupted. If you can see all of the tooth, you can pretty much assume it’s erupted. At that point, 90% of all insurance companies will tell you no, there are no benefits. If you are not happy with that answer, then just ask if there’s a difference in benefits depending on whether your tooth is erupted or impacted. That should help you in case you really can’t tell either way.

When it comes to your dental insurance, benefits for the surgical removal of a tooth is almost usually there. ALMOST. Same question to your insurance rep can be asked. BIG TIP#2: If they ask you if you have a code (which who the hell would know the code for the surgical removal of a tooth unless they actually work in a dental field?), here’s a safe bet: D7210 – surgical remove of an erupted tooth. There you go. You’re welcome.

The bigger problem with 0ral surgery is the anesthesia. We don’t use “gas” here so I’m not even going to go into that as I have no idea if dental insurance covers it or not. We use IV sedation or local anesthesia (the numbing shot to the mouth). Local anesthesia will be covered and is included in the surgery. Logically, what kind of sadist would ever surgically remove a tooth and NOT numb you?? Therefore, there shouldn’t be a separate charge for local.

As for IV Sedation, only a licensed professional can provide this service, so be advised. IV sedation, or “going to sleep” as it’s commonly referred to, is rarely ever considered “medically necessary”, so for those people who say “The tooth is infected and a friend of my cousin’s brother-in-law who works for a veterinarian told me it would be medically necessary for me to go to sleep!”, well your argument is moot.

With that being said, that doesn’t mean your dental insurance won’t cover it. Don’t walk into the surgeon’s office and announce, “I have to go to sleep or I’ll rip the door off the wall when the doctor touches me!” when all you are having done is taking out one abscessed, erupted tooth. You’ll get no sympathy from me or your insurance. Of course, we’ll go ahead and put you to sleep if that’s what you want, but I’ll warn you ahead of time your insurance isn’t going to pay for it and I’m going to collect the charges for it before they even take your blood pressure. If you seriously have a dental-phobia, then you should be willing and able to pay for the “luxury” of going to sleep. And if your insurance does indeed pay towards anesthesia? Well, alleluia! You have excellent benefits. Here’s your refund! BIG TIP #3: if you don’t have the finances to go to sleep, but you don’t like the sound you hear when someone is working on your teeth and mouth? Bring your MP3 player and plug in.

Here’s where things get complicated. Do you know what your Third Molars are? They are the wisdom teeth. The surgical removal of the wisdom teeth breaks all the rules when it comes to insurance benefits. Some medical insurance plans provide benefits specifically for wisdom teeth. Some dental insurance plans specifically exclude benefits for wisdom teeth. It is safe to assume to never assume that while you may know what insurance benefits you have and don’t have, that those benefits apply to those suckers. I don’t recommend calling just once, but twice, and to talk to two different representatives.

As I wrap things up, I would advise you to familiarize yourself with how your medical AND dental insurance may coordinate on benefits for 0ral surgery. I recently had this example: medical insurance only covered impacted wisdom teeth and the dental considered the procedure strictly a medical and had no benefits at all for the specific procedure. What happened was that the patient’s wisdom teeth were all erupted, so no benefits under the medical and none under the dental. All that insurance and no payment whatsoever…just sad. And then there’s the “no duplicate clause”: medical had benefits but the deductible was crazy high ($10,000) and not even close to being met. The claim was then sent to dental, but they had the “no dupe clause” and since medical already processed it, they denied. Again, all that insurance and not a dime was paid out.

Lastly, BIG TIP #4: look at your Explanation of Benefits (EOB) when you get it. Don’t wait until the doctor’s office sends you a statement for balance due and then get your panties in a bunch wondering what the balance is for and call the office and start chewing out the office staff claiming you don’t know what you’re being billed for. I repeat: YOUR insurance is YOUR insurance. I don’t pay the premiums, YOU do. If you want to know what your insurance paid and didn’t pay, call the phone number that came on your EOB and ask someone. And if you get a check with your EOB because your insurance company pays you directly and not the doctor, don’t be a tool and cash the check and spend it on outstanding bills and then not pay your doctor. You will get absolutely no sympathy when you call and say, “I got a check three weeks ago for $500 but I spent it on my cell-phone bill, cable and cigarettes and would like to make payments of $50 a month with you.” That just makes you douchey and a flake.

I’m sure I missed something equally important and as boring, but I have wanted to share this information for a while with you, the ‘net. After a decade of experience at the hospital and now this, I can safely say that only about 90% of policy holders understand the basics of their health insurance. It is complicated, but making the attempt to gather information makes everyone happier, and trust me, I don’t like looking at anyone’s face as they gape at me in open-mouth horror and shock when I deliver a quote of benefits. I don’t want to see your buccal cavity. My boss does.

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5 thoughts on “Your Insurance and You: As Told By Me”

  1. You do know that the people that actually need to know this won’t read it, right? I hear similar crap all he time from patients. They call to ask US if their policy covers vasectomies. I feel like telling them sure they do, but bring your checkbook just in case. (dipshit, call them and find out).

    1. You’re right, Chris. Those that should read this won’t. I guess if they are too lazy or ignorant to call their insurance company, certainly they won’t bother researching it on the internet. But one can dream.

  2. I always love being blamed for someone’s insurance not covering whatever it is like it is MY fault.

    Good explanation, Dawn. Insurance is tricky business.

  3. You make me very happy that I had all of that stuff done when I was on my parents’ insurance! Eventually, I’ll have to have crowns and extractions and stuff like that, and I’ll have to read my coverage plan, but until then, I shall live in the dark!

You can say it here.

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